27061 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
['1NTAC`U
Y OF CUPERTINO nmfmNc-Rr.P�rnrCz PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 f 061
4j.
BUILDING PRDd4:C'1'IDKNiTPICATION G r U
DING ADDRESS: " ///''' SANITARY NO. APPLICATION SUBMITTAL DATE
7sUNITp Ofp
HRS NAME: PHON 'S 'ON'1'RAC I'OR'S NAME: 'IC NO: NIC
wI o« Av►srh Su44A g5 co»6TR C72
I'IF.CI'/ENGTNF.BR: LIC NO: DDREIS:
V AA. PALO AMO �
PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOC, PLUMB MECH
PERMIT ISSUANCE ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 0 ISCRI�ryy us
CZ Thereby affirm that CENSE liCONTRACTOR'SD CLARATIO (commencing with ,TI ``^�1•]/)
pzc Scction'lOtgq of Diviaian3of the Business mJ Rnkssions Cale,and mylicense is in PANELS — 1
Fyy' full reopened effect. rt r 1Y
Z yI ;zenu 4 Lick t., (� UP TO 200 AMPS
coma agrme 4 Contractor Vhal • 201-1000AMPS I.
ZOyt' RC111TECTS DECLARATION OVER IIXIO AMPS SQ.FE FLOOR AREA S/SQ.IT.
O Z^ I understand my plans shall be used us public records.
ryl-ul SIGNS ELECTRICAL
Lianmd Pmfcssionul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. '
�OyF I hereby uffimt that 1 am exempt from the Carttodor's License Law for the
W 3 LL m following mason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F''�wJ which requires a pmrud to construct,alter,improve,doundish,or repair any structure
Sa 2>-7 pnations,nations,
ior to its issuance,also rethe applicant for such permit to file a signed statement POWER DEVICES
u1`4< that he is licensed pursuant to the Provisions of the Comrncmr'a License Law(Chapter
a�o 9(caurnmeng with Section TO(IB)of Division 3o fine Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W-.m or tum he is exnnpnhemfnmpwdthe basis for lhealleged exemption.Any violation of Otl'II,ETg SWITCHES-FI%TURES
�Za Section 9031.5 by any applicant for a peranumbjects the applicant In a civil Penalty of
g nm rump, he-fivehundmA dollers(55W). NEWRFSIDENTIALBLECIR _SQ.FT.
p ❑num
asnwnend'Iheprn"Ify,ormyemplayeeswom wagesas theirsolecompensation, STORIES TYPE CONSTRUCT'1014
L willdm the work,and the structure is not intendedoroffered forsela(See.]Mq Business
and Professions Code:The Commences License Law does not apply to an owner of
property who buiidsorimprovathereom,and whodmssuch workldmselforlhrough his
employees,providedlM1msucmimor
hlmproveenis are not for sale.If.
DCG GROUP RFS.UNITS
however,the building or improvement is sold within one year ofconapletion,the owner- TOTAL:
builder will have the burden of proving That he did oat build or improve for purpose of
_ y
❑ I,res owner of the property.umexclusively contracting wilhlicertaW contractors QTY. PLUMBING PERMIT 1'F.E FLOOD ZONE APN
construct the project(Sec.90,14,Business and Professions Coded The Convector's
License Wwdoesnotapply to an ownwofpfoperty whobuilds orimproves lherean,and PERMIT ISSUANCE
who comnmts for such projects with a comracleds)licensed pursuant o the Counselor's
License Caw. - ALTER-DRAM&VENT-WATER(EA, FEE SUMMARY
❑ 1 am exempt unJerSa. ,B&P C for this reason BACK FLOW PRO'T'ECT.DEVICE SANITARY Y_
N
Owner Date - RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm that i have a cenificate ofconsentto self-insure,or a cenificale of FIXTURES-PER TRAP RECEIPTp
Worker'Compensation Insurance or a cenified copy thereof(Sec.3800,Lab C.)which I PARK FEE Y N
coven all employ«s under this permit. GAS-EA.SYSTEM I INC.4 OUTLETS RF,CFlPT q
Policy M BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby tbmished.
❑ Cerlilied copy is fled wish the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CER'T'IFICATE OF EXEMPTION FROM WORKERS' GRIASETRAP SOILS FEE
COMPENSATION INSURANCE
(This mesion Cowl not be completed iflhe purnat is forone hundred dollars($100) SEWER.SANITARY.STORM FLA.20idn'. EN ERGY FILE
orlem.)
I minify that in the pelformartceofthe work far which this .it is issued,l shall WAI HE 11FA,ER W/VIiNT/HLECTR ,
not employ any person in any manner so m to become subject to the Workers' PAID
Compenuslionlawsof California. Data WATER SYS]BWIREATING Dote Receipt
O z Applicant
z O� NOTICE TO APPLICANT:If,after making this Cerdfiwm of Exemplion,you should NEW RESIDENTIAL PI.MB. SQ,FT. TOTAL:
F p) became subject o the Worker's Compensation provisions of the Labor Code,you most
forthwith comply with such pmvisians or this Permit shell be clamed revoked. BUILDING FEE
y (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
V z IM1ereby effimtlum there iso countermove lending agency for the perfoma
rnce of TOTAL: ELECTRIC FEE
O' the work Is which this permit is issued 1111.909'/,Civ.CJ
Ixndm's Name
0 I .cauluea Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEC
V I certify that 1 have mad this upplicarion and state that the above information is
wrest.lu l reem mom with all cit itemmoyo rdinances ansate lawsrdmin to PERMIT ISSUANCE MECHANICAL PEE
6 PYwi yam g
VF^ Z alsov ingeonmrnniroperl hercbspecti nPze mptants.nes afthis city menter upon the CONSTRUCfIONTAX
above-mentioned prove.indrrready Ind purposes. ALTER OR ADD TO MECH.
(We)agree m save,indcmmpe and keep easy in any
the City o eagani t against
incoitiea,gausr, h purnin,expenses which mvyinany wry mcmeagvnslmid City AIR HANDLING ON]'1'('10IQOIXI CEM)
mseyu a he grunting of thio permit
AIR HANDLING UNIT(OVER 10,000 CFM)
Signet o AppteanV ntmetor Dffc EXI FAUST I IOOD(W/DUCq
PAID
IIA%ARUOLL TATERTALS DISCLOSURE HEATING UNIT(TO 100,1100 FULL Date Receipt k
Will the applicant or future building declarer store or handle haznrdeas imperial HIATINO UNIT(OVER IW,I%Ip BTU) TOTAL:
m afford by the Cuperli no Munic'mal Code,Chapter 9.12,unJ the Hoellh end Safety
Code,Section 2 5s32SU 11 No VENTILATION FAN(SINGLE EPSIG)
Will the upPlicanmrfmure builJin6acupanl use equipment ordevices which emir
BOILER.COMP(3HP OR 100,000 WITH ISSUANCE DATE
hazardous air conmminanls as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10(,0(1()BTU) f[�
DisWm? �� I fA
El Yes 11 No NEW RESIDENTIAL MECH. SQ.PT. ��� G/
1 have reeq
ad the hazardous materials requirements under Chapter fi 95 of the - 21 19a
California Health&Safely Cade,Sections 25505,25533 end 25534. 1 understand that
if the building does nm currently have u tenant,that it is my msptmsibility to edify the I
ocnpant of the m mminetns which must be met prior to issuance of a Certificate of CII Y Ur
Occupancy. - V.�!('plr Ll ,
Owner oramhoriuJ agent Dam TOTAL: ISSUED BY'— V� �I�
OFFICE