27960 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT
LE IRI.AI, PERMI'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL 27960
BUILDING PROJECT IDEN'I IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLIf'ATION SUBMITTAL DATE
�� l J�G/_y rl �✓IN G� •UNITat LOT IfI/E/� k
OWNER. ME: PHONE: CONTRACYOR'S NA LIC NO: --NI—C7 CONTROhp
a/lKE7t/ z
�ARC111'1'IiCI'/ENGINEER: LIC NO: ADDRESS: /r Y Yv A t1f11164
bUr
CONTACT: PHONE: QTY, F,LEGFRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E PLI1Mg MF:CH
PERMITISSUANCE � /rY�'I� El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIUENTIAL JOBDFS.,,1�,.,,,,,
p y.Z thereby effinn that I CENSE licensed uACTOR'SD CLARATIO (commencing with
POO Section 9000).f Div6ion3of the Business and Professions Code,.1 my lieenso is in PANELS
full forty and wffwL SZ �7 UP T021NIAMPS 1
F'4 y`j LicenxC as Lic.p a `
w=,°I Dam Commclor ._y/ 201-i"AMPS
.7 FOyZ ARCHITECI'9 DE �/' OVER 10(X1 AMPS SQ.FT.FLOOR AREA $/SQ.tT.
O Z,Z O I understand my plans shall be used as public records. VVV
P'4 Ila SIGNS ELECTRICAL.
Q J Lwea,ed Pmfessloml
Wee< OWNER-BUILDIiR DECLARATION SPECIAL CIRCUTOMISC,
OaF 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
ty30-rn followingreuon.(Seen..7031.5.Business and Professions Code:Anycity mcoumy TEMP.METER OR POLE INST.
�C,'II
cnnawn,ahcqimprove,demolisM1,or repair any swcture
r
prior 1.its irsuunce,nlanrcgwires themplieum lorsuch pmand m fileasigned smtcmem POWER UIiVICES
� �0 that he is licensedpummon .the pmvisi.ns fthe Comment's License Law(Chapter
d N 9(commencing with Section 70)(Pof Division 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Win, onhat he is exempt herefrom and the basis for the alleged exemption.Any violation of fora p
< Section 0031.5 bOUTLETS-SWITCHES-FIXTURIS
y any applicant ermit subjens the applicant m a civil penalty of a
W prnmare than fee hundred dollars($500), NEW RESII3[�TIAI.ELRCI'N _SQ.FT.
n❑ I,mown.roftho,mperty.ormyempinyceswith wagcaastheirndecrmpensatia., S'I'ONIH ECONSTRUCTION
will do the work.and the structure isnot iromwal moffered forsele(Sec.7MgBusiness
and Professions Code:no Contractor's License Law does not apply m on owner of
progeny whobuddsor improvesthereomand whodoes such workhtioVdforthrough his
own employees,providedthat such improvements=not intendedorofremd formle.If, OC .ROUP RE. UNITS
however,the building(ir improvement is sold withintow,mrofcormlition,the owner- 9 ��
builder will have the harden of proving that he did not build or improve for purpose of
sale.).
❑ I,amwnmofth<propeny,ameadusivelyc.mmrsing withlicenard comracmrsm QTY. PLUMBING PERMIT - FE FLOOD ZONE ppN
construct the project(See.7aPI.Business and Professions Code)The Contractors
License Lawdoesnot apply toanownerofpmparty whobuildsorimpmvestheamn,nndPERMIT ISSUANCE
who enmrumsformell projects withawmilownw(d liaenwed pnrsuammilw C.ntmemry
License Law. AL9'hR-BRAIN&VENT-WATER(EA) ) NY
❑ 1 am exempt undo Sty. ,B&P C!or this reason BACK FLOW PROTECT.DEVICE. ES
SANITARY N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. PT#
WORKMAN COMPENSATION DECLARATION SCH LT Y-
❑ I hereby affirm that l haveacenifcue ideonsent toself-insure,macumilicmeof FTXTUNES-PER TRAP iCF.IITp
Workers'Compensaiioninsu=u eracenir,dcopytherwf(Sw.38W,LohCJwbich KF'E y N
upsew.1,at empl ttWi 'c z/_ RECEIPT
70� Y/ GAS-GA.SYSTEM-I INC.40I1TLL7S
Company_ � B GpIVi51 NFEES
WQortilicd copy 91�cby�mi GAS-EA.SYSTEM-OVER 0.(PA) PIA CK FF.B
❑ Ccnified copy is file)with me city inspersion division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADIN FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP ILS FEE
COMPENSATION INSURANCE
(flossection need not be completed Him,permit is farrow hundred dollars($100) SEWER-SANITARY-STORM EA.20007. EN GY FEE
or leas)
I cenify that in the performance of Nc work for which this permit is issued,l shall WATER]WATER W/VFNT'/ELECI'R
not employ any person in any manner so is;to become subject an the Workers' PAID
Compensation Lawsof Califrmia. Dam WATER SYSTEM/I'RPATING DateReceipt p
Q z Applicant
z0 NOT ICE TO APPLICANT:If,after making this Cenipcoc of Exemption, no should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
rybecome mhjccno the Workers Compensation provisions of the labor Code,you must
1� > forthwith comply with such previsions or this permit shall he deemed revoked. BUILDING FEE
W
z i
CONSTRUCTION LENDING AGENCY SEISMIC Ed
C, Ihereby wE.that the.is a conshunam lemilm gency for the performance of
U O the work for which this permit is issued(Sec.3197,Civ.C.) ELECTRIC FI?L'
Lk. Lender's Name PLUMBING FT
Q lenders Address Q'I-Y, MECHANICAL PERMIT FEE
I certify,that 1 have read This application and stain that the above laws
relating is
7" W) carding Iagree mon,comply
and with mlciryawl county nNinancesand state onnar upon the PERMIT ISSUANCE; MECHANICAL FRF.
U Z buildingeme inated construction,and f..inereby spection
er"r,t.ntativw.fthis cirymemcr upon the
U z above-meminnW progeny for inspection purposes. ALTER OR ADD TO MIiCIL CONSTRUCTION TAX
We)ogres m sav indemnify and keep harmleas the City of Cupertino against
liabil' s,judgments,cosm wndexpenme which may inany wayhecrucagiman said City AIR HANDLING UNIT(TO 10,000 CFM)
acne ofthe granting ofthis permit.
n AIR HANDLING UNIT(OVER 10.000 CFM)
7 7
SMHAUST HOOD % p
' - mrcof ApplicanOCnmmc� Dote PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Nweiptp
Will the applicant wfuture building tKcupantsrore or handle hazadnus memtial HEATING UNIT(OVER 100,(100 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Swoon 25532(.)4
11 Yes VENTILA'T'ION FAN(SINGLE RESID)
�.
Will the applicant or pope,builiingwcupantusc equipmentordevices whichemit
BIL
OT:R-COMP(IHPOR IW,tNp BTU) �51 SPIOCE DATE
zardous air conasminants as defined by the Bay Area Air Quality Management
stria BOILER-COMP(OVER 100,000 BTU)
I
❑Yes pot k NEW RESIDENTIAL MHCTT. SQ.FT. APR 191995
1 have sad the moue s materiae requimmetns under Chapter 6.95 of the /•'��
Califomia Health&Safety Code,Sections 25505,25533 and 25534. Iunderstandthat 10 Ot- (a(drt�{/�
oftbeb (ding does not currently have a tenant,that it is my responsibll'y to notify the
ecu, f t quiremm�ts which must M1e met prior IDI iVowne CeT'ficam of
o e ��
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE