27041 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO l.11.11Ni:=F.lau CAL PERMITNO.
BUILDING DIVISION APPI.ICATION/PERMIT PLUMBING-MI?CHANICAI,127041
IIUILUINU VRf1.IRCl'IDEN'I'IN'ICA'1'ION
BUILDING ADDRP_SS:,S� V I C SANI'T'ARY NO. AI'I'LICA'DDN SUBMIFFALDATE
1 0 J'9D w`J V UNIT LOTH
OWN iR NAME: f x fGliPNti:6A) f //'� CO I'll IC {ate
��ll.V. NIC CONTROhp
ARCHITECT/ENGINEER: LIC NO: AD WA ❑
Cffq��Fr''I'ACI': PHONE:
/1 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE/VI,1/ BLDG ELECT PLUME m4clije
❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �IPI']ON
p�Z Thereby affil nthalem licensed underproviggqqqqinns ofChapter9(commencing with
�00 Sectio.70001af D of IF Business an�+essjy.a Cod.an/mylicenseisin pANE1S
5dE full li+rceanAc fie r. �n eCJJ /Y/•�
r6Zm
Live Clay Lit.# UP TO 2W AMPS
m 6 y Data Contractor 201-100(1 AMPS
F Z' ARCHIIDCTS DECL SQ.IT.FLOOR AREA E/SQ.IT.
r3 p 1 understand my plans shall be used as public recoNs. OVER 1000 AMPS
ear W SIGNS ELECTRICAL
QY J Licensed Professional
�ya6 OWNER-BUILDER DECLARATION SPECIAL CIRCUFDMISC.
O pE 1 hereby alum+mm I um exempt from the Contmeou's License-L.,birth
m 3 W ya following reason.(Section 1031.5,Businessand Professions Cole:Any city m county TEMP.METER OR POLE INST.
which requires a pennant to construct,alter,improve,demolish,or repair any swnurt
M� prior to its issuance.also requires the applicant for such permit to file a signed statement POWER DEVICES
0 that he is Ii<en ad pursuant to the Provisions of the Contractors License Law(Chapter
0. 0 ' 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
al_y or that he is exempt herefrom and the basis for the alleged exemption.Any violationaf OUTLETS-SWITCHES-FIXTURES
QSection 1031.5 by any applicant for a permit subjects the applicant o a civil penalty of
nrnre than five hundreA dollars lS5001. NEW RESIDHN'PIAL ELECTR _SQ.FP.
no n❑ I,asowncra(thcpropeny.ormyemployeeswith waguestheirsolemmpemetion, STORIES TYPE CONS I RUM ION
p,3. will do the w.,k,..d the xwaure isnot imendedorof@red for mle(Sa.70i4,Business
and Professions Cade:The Comrudnr's License Law does not apply to son owner of
pmpenywhobuilds ar improves Merton,and who d«such work himmlf arthrough his
own cmpluyces,pmvided thatxuch improvemenbae not inhndedoroffemd Tarsale.If,
OCC.GROUP k15.UNITS
however,the building or Improvement is sold within one year of oontpletion,the owner -TOTAL:
builder will have the hurcem of proving that he did not build or improve for purpose of
❑ I,asuwneroDhepropeay.w+endusively connecting with licensed cnnwcmrsm QI'Y. PLUMBING PERMIT FF.E FLOOD ZONE APN
conarect the project(Sec.10 cl,Business and Professions Code:)The Contracture PERMIT ISSUANCE
License Law d«s nal apply to an owner of property who bui Ids«improves thereon,and
who contracts forxuch pmjects with acommenods)licensed pursuant ntre Contractors
License Lew. AI:IRR-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under See. ,B&P C far This reaxoa BACK FLOW PROTECT.DEVICEOUTSIDE FEES
SANITARY Y N
Owner Data RECEIPfp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCIIOOLTA% YN
❑ I hereby affmn that i have a certificate ofcorment to self-insure,or a certificate of RECEIPT#
IIXTURPS-PER TRAP
swun,rs'Compensminnl su�reqce rvicenified copyt Sec Jg00,Luh CJ which PARK FEF. Y N
mall emplo r/Li1 it GAS-EA.SYSI'EM-I INC.40UTLETS RECF.IPI'M
Policy# BUILDING DIVISION FEES
Grmpwr GAS-EA.SYSTF -OVER 4(13A) PLANCHP.CK FEE
❑iii� C if h
ani dcopy is filed with live city inspects division. - GREASIpINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF E%Eb1PION FROM 01 ."RS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANC
Marcell nadnotbecompletelifthepre dreddollaurVii0) :WER-SANITARY-STORM IA.200 ENERGY FEE
or less.)
I real l'y tbmr the perfowvnce of the work( hit isXy d,Iehall WATERIIEATFRW/VENT/ELECTR
net employ any in any towner so t oma subja #tE Vorken PAID
Compensationlsws Califomia Date J WATERSYSTEMfMFATING Data Receipt If
0 z AFPlleam
Z O NOTICETOAPPLICA :IL. k this Certificate a prion,you sht dW RILSIDENTIAL PLMB. SQ.P. TOTAL:
ri;G becomesubjecttotheW ke ionprovur f .ebur Cale,y ust
� , forthwith comply with sus provisions rt 's pcwi s deemed monk BUILDING FEE
aq CONS UCTIO v GENCY SEISMIC FEE
z 1 hereby affirm that thesonswction lending agency for a performwce of
V Q lhewmkfarn
whialabapeNtrisuad(Sa.3091,Civ.C.) TOTAL: ELECTRICEIM
0 tA•udcr.Name
F tenders Address QTY. MEC HANICAL PERMIT' FEE PLUMBING FEE
y` V 1 candy Nm 1 have rend is up cation end stat "'re
shove infowetinn is
r0. correct.Ixgr«mn+mply with all city or m marcs sndsmm low.reliongm PERMIT ISSUANCE I� /• MECIIANICALFEE , 1•
U., building cnnswmion,wdhertby.whonmrepresnnmlives ofthis city wentarupouthe CONSTRUCTIONTA% `�•
I..I 7 abrwe-mem Med prnpeny for inspection purposes. ALTER OR ADD TO MECH.
r7 (We) e,indemnify and kap harmless the City of Cupcninu.,.last
liabilities, gm t, osiswd exparmnahicherayinanyw.yac<mea ainasaid Ciry AIR HANDLING UN PGO 1(1,000 CFM)
w i Ming of this pewit. l
I AIR HANDLING UNIT(OVER If1,0110 CFM)
Signature Applinmt/Cnmrecmr pate 17XIIAUST HOOD(W/DUCT) PAID
HAZARDOUS MAT17RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or more building occupant store or handle hazwdoes materialHEATING UNIT(OVER IOO,IXq BTU) '1'OTA L:
as defined by the Cupertino Municipal Code,Chapter 9.12,read the Hadth add Safety
Cale,Section Y55532m)1 I❑No VFNTTLATION FAN(SINGLE RRSID)
BOILER-COMP(JHP OR H 0.0i BTU) ISSUANCE DATE
WIIlthe ucompronmrlmum defined
by the Bay Area Air
M hichemit P A ' D
hamrdam air conmminwii as definW by the Bey Arca Air Quality Management BOILER-COMP(OVER 100,0(10 BTU) Y1
DisWcC
❑Y. ❑No - NEW R17SIDEN'1'IAL MECH.-SQ.FT. _ FEBly 19,7z)
•- 'I bane read the hvenrdoas mmenals requirtments under Chapter 695 of the r
Califomia Heoldi&Safety Code.Sections 25505,25533 and 25534. 1 undcrawd that
ame bmlaing a«a nm<armnar nate a tenant,that it is my respensiboity to many the CITY OF UU+'EH
weapon of the rentraments which must M met prior to Issuance of a Certificate of
Occupancy.
Owner or nmhoriud ngmn Dene 1'Ol'AL: ISSUED BYr
OFFICE