27255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONL
CITY OF G'I FRTINO RUII:RTh PERMIT NO.
APPLICATION/PERMIT PLUMPING CI IDENTICAL
RLKLUINC )IVISION NUILDING Eo.IEC'1'IDEN'nh'ICATION 27255
BWLDING ADDRESS: �g �� SANITARY NO. APPLICATION SUBMITTAL DATE
��`3gs �ia�ENS' C UNIT# LOT#
OWNERS NAME: }��.[JPHONE. CO RA(-TOR'SNAMC: C •' LIC NO:
/ZA V/ 15k-r I� NeCON Y ryS N/C CONTROL#
4iNG1 EI3R: �� ADDRESS:
n/ 9'!>> / s AcNp,�n/ SANEl
C'ON/'I'ACI': PHONE: '?'hh Q. t<y,',
J I'Y/Ay/V�. SHKH 1j.0g �q 1 S QTY `i NN ECEGTRIC PPRMI'I's'M n' '� �,*:'FEE+:" ':BUILDING PERMIT INFO
"`-'�Y.]CA kc W BLDG LECf PLUMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
pyz Ihereby affrd than Lou licensed underprovisions ofChepter9(commencing with JOB ESCRIITION
ts100 Semicon]000)of Division 3ofthe Business it Professions Code,and my license is in PANE(
fy-U6 full foteesnd effect / 1
y6W D'xnnse Class Contractor!4 a ,, 1 UP TO 200 AMPS k 11AU)
N 201-1000 AMPS '`r yybb �^l
ROy2� _y�?�y`Iy�TF.C'1'S DECIARA ON OVER 1000 AMPS
]fIn7A S/SQ.IT.
gO z,.•tt,.Q,�a,]4]I I understund my plans shall M used as puhlic..cords.
SIGNS
ICAL
y ¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ���
Licensed Professional V
�00.0 I hereby affirm that I am exempt frmm the Contractor's License Law for the
m3u.Via following Mason,(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
m'I whichrnryiress peemit..emarw<L atter.improve,demdllah,m repair any swemm a g�
K�Q7 prior m its is,namce,atsnreyaim,the appl wool for such peemiuo filen signed statement POWER DEVICES V .J
W�p O that he is licensed jammuntto the provisions of the Contmctor'e License Lew(Chapter V
2aois' 9(contmencing with Securing]000)of Division 3ofBm Business and ponfossions Cada? SWIMMING POOL ELECTRIC VALUATION
I
❑,n Section 7031.5 by nyapth,mmmnt f the basis foujeasegNesemption.Aivilprationaf OUTIETS-SWITCHES-FIXTURES
FSG notSecmom
than five
hundred
dollars
dog,epplimm macivil pesultyof vas /
centnot more then five hundred dollars(5500). NEW RESIDENTIAL ELECTR 5 .FI'.
❑ I,asownenefthepmpedy,ormyemployeeswith wagesus theirsolecompematioa, _SQ.FT. '1'YPL'CONSTRl1CT'[ON
y 3— will Jmhe work,Code,
s o Con mpainmddedorr ow does not
apply
to sm owner
igs
of
and I'rofcasions Code:TTe Connector's License Law does not apply to an owner of
pmpeny whobuildsorimproves themon,and wh000es such work himselforthroughhls OCGGROUP RES.UNITS
pin employees,providedthauuch improvementsarenot intendcdoroffcredforside.If,
however,the building orimpmvement is sold within oneyearof completion,the owner-
bullderwillhavetheburdenof that he did not build or int for f TOTAL:
proving prove purpown
sola.). ' r .•
❑ I,asownerofthepmpery,amexclusivelyconi etingwiNlicen eJ nlrectonto QTY.4, PLUMBING:PERMIT. - . ;FEE FLOOD ZONE APN
conswct the project(Sec.TaC.Business and Professions Code:)no Contractor's
License Law does not apply to anownerofproperry whohuilds in improves thereon,and PERMIT ISSUANCE
who contracts forsuch pmjccr with acontrnctor(s)licensed pursusat to the Contractor's ALTER-DRAIN&VENT-WATER EA FEC SUMMARY
License Law. ( 1
❑ I am exempt under Sec. ,B&PC for this Mason TSI).GEIS
BACK FLOW PROTECT.DEVICE SANITARY YN_
tai Owner - Don DRAINS-FLOOR,ROOF,AREA,CONDV
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
I hereby affirm that l have a certificate ofcomem to self-imum,or a cenific tle of RECEIPT'N
Ijeri Compensation Insurance oracerified copy mermf(Sec.3800,Lab CJFIXTURES-PER TRAPwhich PARK II3E YN
rs all em RECEIPT#
pm ur n' GAS-EA.SYSTEiM-I INC.4 OUTLETS
Policy# BUILDING DIVISION FRES
Company 11 ,ly GAS-EA.SYSTEM-OVER4(EA) PLANCIIF KFEE
Criiliedcopy is l eyfumishe .
[T Cenified copy is fled with the city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section nead not be completed ifdoe permit is forcing,hundred dollars(3100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Tess.)
I eerily thin in the pernornsoce of the work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ any,person in any mender so ss to become subject to the Worker' PAID
Coainginationlawsof California Date WATER SYSTEM/TREATING Data Receipt#
0 z Applicant
C) f
z — NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLACE. SQ.FT. TOTAL:
FCM become subjauo me Worker's Compensation provisions of me Labor Code,you must
> foMwith comply with such provisions or this permit shell be deamed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm dont mere I,.conauuction lending agency for the pedo...of agisss
TOTAL: ELECTRIC FEE
the work for whicM1 ole permit is issued(Sea.309],Civ.CJ
U Lender's Name
v" F Lcndeh Address QTY.ra °'..MECHANICALPERMIT . yFEE PLUMBING FEE
U I certify that 1 have read this application and spite that the above information is '
R! coved. lagreemcomply with ell<iry end county oNinances end atete lows rtlming to PERMIT ISSUANCE MECHANICAL FEE
_ t, building conswnion.and herebyaumorier representativemfdois city..emerupon the CONSTRUCTION TAX
U z nhwe-memim od property for insper ion purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of CLpenino against
liahilities,judgments.costs and expenses w ' may inuny way ac eagainatsoid Ciry AIR HANDLING UNIT(TO 1(1,0011 CPM)
to e the granting o
t /,IjfAIR HANDLING UNIT(OVER 10,"CFM)
S u of Ap n Con Date EXHAUST HOOD(W))UC'i
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt#
Will the applicant or future building oecupmt store or handle hevvdous material
as defined by On Cupertino Municipal Cole,Chapter 9.12,and the Ileahh and Safety HEATING UNI'1'(OVER I00,00)BTU) '101 AL:
Calc,Section 25532(e)Y
13 Yes 13 No VENTILATION FAN(SINGLE RESID)
BOILER- ISSUANCE DATE
Will mea IicumnrfmurehuilJlm COMP(JIIPOR ItNI,W1I BTU)
pp g by the
A ui Air Quality carni hemit
Go, 11 s air contaminants ns defined by the Bay A.Air Quality Management BOILER.COMP(OVER 100,(X10 BTU)
IN F)ietricTl
❑Yox ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have caul{the haurJoux materials requirements under Chapter 6.95 of the
iffive ail mega&ocCole,Seniors25505,t it
1undermnd that
if the hulloing rices not mentacurrently have a tenant,that it is my responsibilityuanoae notify the
occupant of doe requirements which our be met prior 1m issuance of a Certificate of
Occupancy.
Owner or amhmined agran Date TOTAL: ISSUED BY:
OFFICE