27347 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - XTICAL PF.RMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MRCBANICAL 2 7 3 4 7
- - BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �L SANITARY NO. APPLICATION SUBMITTAL DATE
2 — AT# LOT#
O N NE: CONT C'I'OR'S NAMEli
:
N/C CONTROL#
`� AR HI T G EER: LIC NO: ADDRESS ❑
CONTACT: PHONE: rt'YWk +e 4 s A = a "` .!w s n ��HUIEDING PERMIT INFO.
QThgY �'� ', ELy;T gPERMIT4 "EPEE .t o
a s. ` ,s S'Si3': BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb ffinn thatlum lice ed antler rovisionsofCha mr9 commencin th LOB DFSCRIPI']ON
q TGZ Ya P P < gwi
�il 00 Seollon 70DE of D f alines and Professions Code,and my license is in PANELS
a W w PoII forty and of cl.
F Z pl Licenu Claes p UP TO 200 AMPS
m 5 on Dam Cimmucmr 201-1000 AMPS
Z FO ti� ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—M I understand my plans shall be used as public records.
PmJ`d SIGNS ELECTRICAL
6'�"d ,J Licensed Pmfessmnal
�K OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
t0,6 1 hereby n.abirm(Se that 1 am exempt from the Cnnuano o License Law for the
3 0.m fallowing reason.(Section 703 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
y O� wilrM1 requires n pernh re quires the
alter,improve,demolish,or repair any stm.mre
¢� prior to issuance,also requires the applicant for such pe,miuofile aligned statement POWER DEVICES
W
p,AC that he is licensed pwsranuo the provisions of the Contractors License Law(Chapter
9(commercial with Section 7001 of Division 3o1 the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS Q,
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of FIXTURES
G not mom than Eve handled dollars($50). NEW RESIDENTIAL ELECTR _SQ.Fq
W m ❑do
wrk,anheproperty,ormndineyerborofwagesasmei(sole compensiiess STORIES TYPE CONSTRllLTION
a _ will do me coons C d e:The Cite is tris License
a w dosed s not apply to an Business
'
and profession Cele:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who duss such work himulfor through his
own employees,pmvidedthat such improvements we notimended orofferotl foraale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner- tTA1
sale.)
builder will have the burden ofptoving that be did not build or improve for purpose of
w §$^ v ihaa .,
❑ las owne,oghe property,am exclusively contracting with licensed contractors q7-W, tT PLUM PERMIT'S r ] FEE. ' FLOOD ZONE APN
construct the Project(Sec.7044,Business and Professions Code;)The Cowl Inc.
License Lawdoesrmt apply to an uwnerofpropery who buildsmimprover thereon,end PERMITI DAN
whonsLaw.forsmch projects with acon[racmr(s)licensed pursuant to the Contractor's ALTER-
License Law. D ENT-WA EREA) 'FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK . PR EC DEVICE UTSID-FEES
SANITARY Y_N_
Owner Date. DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT It WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherebyaffirm that l have acertifiwte ofeanseot itself-insure.orettrtificateof FlXTURES-PF.R TRAP RECEIPT#
Workers'Compensation Insurance or o certified copy thereof(Sea 3800,Lab C.)which PARK FEE Y N
covers all employcc's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER (EA)C1Certified copy is hereby famished. ( PLANCIIECK FEE
❑ Certiticd copy is filed wird the city inspersion division. GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisursi.nneWnotbecomplemdifthep=itis fo rro huntlred dollars(SIDE) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or la'..)
Icertify that in the Performance of the work fm which this permit is issued,I shall W TER W/VENT/ELECTR
not employ any person in any manner so a,m become subject 1.the Workers' PAID
Compersadon Lawsof Califrmie, Data WATER SY
Applicant BM/1'REATING Date Receipt#
z
NOTICETOAPPI,ICANT:lf,aftermakingthls Certificateaf Exemptioo,yaush.uld NEWRESIDENTIALPLMB. SQ.FE TOTAL:
[" (q become smbjecuothe Workers Compensation provisions of the Labor Code,you must
IFF'" . forthwith comply with such provisions or this permit shall be,deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm Oauhere is a concoction lending agency for me performance of
U O the work for which this permit is issued(Sec,3(19],Civ.C.) TO ELECTRIC FEE
Lenders Name
Lanae.Address Q'Imr,«'' MECHANICAL PERMIT,t s ;AEE PLUMBING FEE
O U I cerofy that I have read this application and state that the above mformation is
PWi correct. l agree to comply with all city cod only ordinances and state laws exhaling to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorim repo entatiessofthis city in enter upon the
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree m'iwv andggqsmfy and keep hamtless d Cy r be t
liabilities,jidgments,cie�i9p'asOcaseswhich meymany vcry� AIR HANDLING UNIT(TO BLOW CPM)
in consequence of g ag thisperml
AIR HANDLING UNIT(OVER 10,00 CFM)
SI t of Applicant/Commnor Dem EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00 BTU) Dam Receipt#
Will the applicant or future building occupant store of handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,00 BTU) TOTAL:
Code,Section 25532(.)? -
11 Yet 0N VENTILATION PAN(SING LE RESID)
HOLLER-COME(311P OR 100,000 BTU) ISSU NCEDATE
Will tai(applicant
co la.manus s defined
by the Bayut Aulp Aw Q aevi Managemees which nt
p a jD
bazardnwa air contaminants as Defined by the Bey Area Nr Quality Management BOILER-COME(OVER 100,000 BTU)oil /1
DIS ct7
LC-fi ❑Yes 0N NEW RESIDENTIAL MECH. SQ.FT. Nov 281994
fo�i.
read the hazardous materials revidlemmms code,Chapter fi95 of the y
ealth&Safety Code,Sections 25505,25533 anit25534. I understand thatls��yg does amt currently have a tenant,mat it is my responsibility m noNythe VTuhthe nequhements which must be met po,m c...noe of.Certificate of
horized agent Data TOTAL: ISSUED BY:�
OFFICE