27296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
L
CITY OF CUPERTINO B ILII G-F,LF. 'I RILAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL (�
BUILDING DIVISION BUILDING PROJECTIDF.NTIFICATION' L
BUILDING ADDRESS: `,./ n SANITARY NO. APPLICATION SUBMITTAL DATI
55 I r �rc IT« �c'o�f LOT f
OWNERS NAME:. PH � ' 18 CO 001 NAh]E _ r LIC� O
4rJL ,IT11`� i&L NIC CONTROLp
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTAC'U PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRAM dunderOR'SDis o(Ch TION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
WCOnw� IheobyaffinnNmlamliceBusinssand irofesionsCods,andmmendngwith n OOO FLLLAMLE
u100 Scction7IXq)nf Division3of[M1e Business and Professions Cade,and my license is in PANELS LIV
aVF full force and effecVl �� UPT021p AMPS
I FZm I.icerecCl �� t�aa Tilio Cmau �E k�l._{'�L
w6a Ux[e '�l,ic.# wl
F y z, ARCHITECTS DECLAR TION 201-IOW AMPS SQ.Flt FLOOR AREA E/SQ.FT.
Ci,_ IOW AMPS
CZ-0 1 understand my plans shall be..J as Public records.
F_.1=m SIGNS ELECTRICAL
6Y:�j Licensed Professional
a
aa< OWNERBUILDERDECLARATION SPECIAL CIRCUIOMISC.
XOyF 1 hemby affirm that 1 am exempt from the Cocoons Co License Law herdic
w 3 u.vt following which
eq ua s aper it to con LS.Business and prove,demob Cade:Any city or county TEMP.METER OR POLE INST.
hwO< whirM1 rcquimsopermitnetonsduealmg Improve,Mermitt,ore a sig anyswcture
Ew}o thin nossissuanc piss requires provisions
of the CouenniuoLicen signedstatement POWER DEVICES
tai a Nm be is lieenscJ puissant to the provninns of the Contracmrs Licenu Law(Chapter
a Xp� 9(commencing with Section7(Xp)of Division 3ofthe Business and Profession+Cale) SWIMMING POOL ELECTRIC VALUATION
W'2y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of ON'LETS-SWITCHFS-
�%Y
Section 7031.5 by any applicant for a permit subjects the split icon[m a civil penalty of FIXTURES
��� no,come than five hundred dollars(S5W).
�_� ❑ I,u+nwnernfthe propCny,nrmyemployceswith wegesaaheirsolecomperaation, NEW RESIDENTIALELECfR _SQ.FT. STORIES TYPECONSTRUCI'IOP
will do the work,and the structure is not intended nndfered forsale Nev,7044,Business
rand Professions Cale:The Contractors License Law does not apply to an owner of
pnrpeny won builds nr improve,themon,and who does such work himself,.[hough his
o�nemployees,pwvidedthatsuchimpmvemenisamnotintendMorofferedforsale. OCC.GROUP RES.UNITS
however,Nc buildingor improvement is sold wiNlnone yearo(completions theowner- TOTAL:
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
❑ Las ownerothe property,am exclusively contracting with licensed convactomto QTY. PLUMBING PERMIT FEE FLOOD_ZONE ANN
construct the project(Sec.7044.Business and Profession,Cale:)The Commnars
License Lawdoes not apply to an ownerofpropeny wholmAdsorimproves thereon,and PERMIT ISSUANCE
License law�forsocn pmjectswi[hecontrac[nis)licensed pursuant to the Conm¢mrs ALTER-DRAIN&V 0DF,;CONC
)
FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this raazon BACK FLOW TROT . OUTSIUIi FfiES
SANITARY Y_NOwner Date DRAINS f�R
F . RECEIPT'«
WORKMAN COMPENSATION DECLARATIONSCHOOLTAX Y N
Cl Thereby affirm thallh0veacenificam of conunuo ulf-insure,oracenificme of PX ORA RECEIPT'«
Worket.'Cmployees lnsurmse cru certified coNcreof(Sec3gWLb CJ hihARK ME Y Nammrsall employees undenhis permit a f' 1O/p A GAS-FA. 11 C.40 I. RECEIPT«Paliy« l-1 BUILDING DIVISION FEES
Company ( L E/�Al3 GAS-EA. OV 4(EA) PLANCIIECKFEF.
❑ Certified copy is hereby famished
IA' CenificJ cnpY is file)with the Ci[y inspersion division. GREASEANDUS RL WASTE.INTERCEPTOR
J� GRADING Ff:E
CERDFICA9'E OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This union neednm he completed if Nc permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM FA.2WFE ENERGY ME
nr less.)
I ccnifythat in Neperfonneace oflhewa,k for which thispcnnit is issued,I buill WATER HEATER W/VENT/ELECTR
not employ my person in any manner so as in become subject to the Workers PAID
z Compcnsmmn Lawsof Colilbmia. Date WATER SYSTEMOREATING Data Rcccip[«
Applicant
OQ NOTICE TO APPLICANT:If,after musing this Cmificumof Eaempti......should NEW RESIDENTIAL PLMB, SQ,FT. TOTAL:
(A become$objecttm
to Workers Compeation provisions ofthe Labor Code,you must
forthwith comply with such provisions or'his permit shall he deemed revoked. BUILDING FEE
V4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
p z I bcechy,affirm that there is a construction lending agency for the perfommnre of
L) Q the work for which this permit is issued(Sec.3697,Civ.C.) TOTAL: ELECTRIC FEE
Utilities Name
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
CL7 I earthy that I have read this application and state that the above information is
correct.Iagree In comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICAL
and FEE
_ buildingconsuunion, herchyauNonu represemmise,mNis city,.aeia,.ponthe
U z shove mentioned progeny for inspection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
We)agree to save,indemnify and keep barmlcxs the City of Cupertino against
liabilaies,judgmen,cos[.sand expenses which may in any way name against said City AIR HANDLING UNIT(TO I0,pW CPM)
in coannquence of the graining of this pwrmt.
AIR HANDLING UNIT(OVER 10,D)d CFM)
Signature of A,IivmVCmmummr Dole EXHAUST HOOD(WNUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW.000 BTU) eceipt
Will the fit Cupertino
Mu buildingoctagonstmtor handle Health
material
as dr,Sed iby on 25 Cupertino Municipal Code Chapter 9.12,and the licalN and Safety HEATING UNIT(OVER I 4.000 BTU) TOTAL:
Crile,Section 25532(0)?
Cl Yes �flo VENTILATION FAN(SINGLE RFSID)
Will Neapplicanmrfmure building occupant usecyuipmemordeviceswbichemi[ BOILER-COMP(311P OR I00,000 BTU)
hazardous air comaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
Dlanatl
❑Yes �6o NEW RESIDENJAN 31995
TIAL M[CH. SQ.FT.
1 have read the hav[Mous mmcrials requirements under Chapter 6.95 of the CITY J
CAdminin Health&Safety Cola Sections 25505,25533 and unrsd NC
25534. 1 demn
at V Uf GUrtfi l tryO
ifthe building docs it currently have a tenon,Na[i[is my responsibility[o notify Ne
Oesup t of the requirements e i m s[hem prior m issuance of a Ccnifica
Owner..'a...xxOrIcan Date ISSUED BY:
OFFICE