27736 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILI�Etar-M AL PERMIT NO,
APPLICATION/PERMIT PLUMHING-MF.CIIANI27736_7 7 3
14UII,DING DIVISION BI111.Uli P
INN13JECT'IURN'I'IFICKICA'I'IONi - G
BUILDING ADDRESS: ,�1Y� �/s 1J, * SANITARY NO. APPLICATIIOONN SU�B.,MGTAL DATE
161 OL Sr � �`e v 9,NI'r# LOT# 12�pLA
OW iRS P� E' CONRA OR'S NA LIC NO: l VqIGv
.r <f NIC CONTROL#
RCHI'TECIENGINEER: LIC NO: AD �71 (y ❑
CONI'ACI': PHONE: QTY. ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
BLDG ELE PLUMB M
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DfiCLARATION pppLIANCES-RESIDIiNTIALQ'it
IPJ02, Ih7")of ffrm(hm l 3 of the
Business std pr fesions Cumr9dd mmecense with
~SIOI-.. full(Section7 mild efa Division the Business add professions Code,anti my license is in PANELS
FZW 'a nese Class �� Lic.p 4v f�k �� 1 UPT0200AMPS
,,-oar te
Contractor 201-IWII AMPS
70yz lundermnd�yy plans shallhusedazpublic RmoMsNa OVER flat AMPS SQ.FT.FLUOR AREA
Cz—❑
SIGNS T:LE,IRICAL
�,0y� Licensed Profir.mard
�t+iU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
.?dU I hereby affirm that I'am exempt from the Contractor's License Law Br the
bat ice following measure.(Section 7031.5,Business and professions Code:Any city or county TEMP.METER OR POLE INST.
F-Y.O¢ which.quires a pandit m cit carat.alter,improve,demolish,m repah any structure
i� prior to its issuance,also requires the applicant(orsuch Permit o file a signed statement POWER DEVICES
W p0
that Le is licensed parsdnut to the provisions ofrhe Contractor's License Law(Chapter
S 9Qommcncm lltSection7f%MIIof Division 3of0e Bloderaaund Profusions Code) SWIMMING POOL ELECTRIC
Swi VALUATION
�m
orOat703 1.5 by mhemfromand the Poundis .bj bthede liesum n.Any ivilpeation of OUTLETS.SWITCHES-FIXTURES
E-z< Section703than five
anydreddmotfar apermit subjects the appliwmtoacivil pcnahy of
$ I more than Eve hundred dollar($500).n❑ I,asnwnerrfthapm I yempy g pte NEW kES1UENTIALELIiCTR _SQ.FT.
per y.orm to ed or all moa esaselei(Sm.cam remien. STORIES l'VPL CONSTRUCTION
y3°- will dothe won,and the nostructure isnm intendedorofwdoesotted orapply 1.. Rosiness
and Professions Calc:The Commnors License Law does not apply Id w owner of
propenywbobuildsmimproves thereon,andwhodressuchwork hitnselforthmugh his
employees,provided that such improvementsam not intendedoroffered forsale.If, OCC GROUT' RES.UNITS
however.the building or improvement is sold within one yearofcompletion,Ocowerr- TO
builder will have the harden of proving the,he did not build or improve for purinse of
le.).
❑ I.asownerofthepmo ay,amexclusivelyconmetingwithlicensedcontr.norm QTY. PLUMBING PERMIT FRE FLOOD ZONE MIN
conswct the projmt(Sec.7044,Business mod Professions Cr le:)The Comnmtor's
License Law docsnot apply to an ownersdpropeny who builds or improves lhemon,wd PERMIT ISSUANCE
,m Darlocts forwch projects with.ronnactods)licensed purotal to the Contractor's
License Law. ALTER (HA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mssan BACK FLOW PROTECT.DEVICE SANITARY Y OUTSIDEFIRES
_NOwner Data DRAINS-PhpOR,ROOP,AREA,COND. RF.CEIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I herebyiffirm that l have a certificate ofconsentto self-insum,or a modicum of FlXTVRL'S-PFR TRAP RECEII'Tp
mkcr%Compcnsetion Insurance orecertified copy thrnnfl5ec.3AW,Isb CJ which PARK FEE Y N_
coversallempleyere's underthispermit' GAS-EA.SYSTEM-1 INCA OUTLI IS BUILDING
Policy p BUILDING DIVISION FEES
Company GAS-HygYSTEM-OVER 4(EA) PLANCHECK PER
❑ Certifiedcnpyishwebyfumished.
ElCenifiM copy is filed with the city inspection divica JLqkSAFjUSnL WASTE INT'ERCEPT'OR GRADING FEE
CERTIFICATE OP EXEMPTION IB ,RS' GRFA Ii TRAP SOILS IIiC
COMPENSATION INSURANC
or less.) res section neW oat becompleted if the permit is for
he II�I$1 ) SEWER-SANITARY-STORM PA.2001T. ENERGY FEE
I cenify thin in the performance ofthe work for which th permiit is�is ed,I shall WAT17R HEATER W/VIiNT/ELF.C9'R
not employ any prison in any n as m became s,ihja,t to the Workers' PAID
Companation Laws df C.Iifomia. Data sit WATER SYSTENVTREATING
Data Receipt p
0 z Applicant
Z NOTICE TO APPLICANT.If.after making this Cenifcamof Exemption.ymitiould NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
Fq]
became subject o the Workers Compensation provisions ofthe labor Code.you must
� ; forthwith comply wdh such provisions or his pennllsh.11 be deemed decrier. BUILDING FEE
0. �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
U2 I hereby afford thatthem is a construction lending agency for the performance of
0 the work for which this permit is issued(So..3097,Civ.C.) TOTAL: ELECTRIC FEE qn
Lenders Name •" tt PLUMBING FEC
O U Lenders Address QTY, v MECHANICAL PERMIT s '. F G
1 renify that I have read this application and state that the above information is
Facond el agree to comply with all city most county ordinances mod nate laws delattog to 1 PERMIT ISSUANCE MFCIIANICAL FE
building construction,and hereby awhorize representatives alibis,city to enter upon the CONSTRUCfION'1'AX
U 7 above men tined property for inspection perp.,. ALTER OIt AUD TO MIiCl1.
(We)agree to save,indemnify and kmp harmless the City of Captor,......inti
Imbililmajudgmems,cmas wdexpenses whichmay in any wayucerueagaiwt said City AIR HANDLING UNIT(TO IQWO C17M)
in conuqu ce ohhe g din f I permit.
aAIR HANDLING UNIT(OVER 10,"CFM)
Tignmureof AptpIjrmaVCw.mU r )ate EXHAUST'1I00D(W/DUCT)
PAID
I TAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10B."BTU) \ Date cipl
Will the applicant or future building occumm store or handle hazardous material
as dcfncd by tho Cupertino Mudieipnl Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVIiR IOO,IMq BITI) T
Code,Section 25532(a)7
Cl Yes ❑No VENTILATION FAN(SINGLE RCSID) �S
Will the applicant or Etmrebnildingoccupantuseequipment ordevices whichemit
BOILER-COMP(3HP OR IM."BTU) ISSUANCE DATE
.mous air comuminams as defined by the Bay Area Air Quality Mmoagemcm BOILER-COMP(OVER I(K),000 BTU)
slid] El Yes ® D
Y<s ❑No NEW RCSIDENTIAL MECH. SQ.IT.
1 have read the hazardous m
materials mitaireems under Chapter 6.95 of the 40�C 7
California Health&Safety Code,Sections 25505,25533 mod 25534. I understand that71
�s/9
if the building does nm cunemly hove a..nam.thsl d is my responsibility to notify Ne - `ai/y
occupant of the maptirtments which must be at prim m isswnce of s CMlfcate of Uf`L
ae.pmoey. U
Owner m uuthorieul agmnt DueP fdkW ISSUBD BY:
OFFICE