27273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - El:rc'I'RTL�A- PeaMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
WILDING PROJECT IDENI'IF'ICA'I'ION 27273
BUILDING ADDRESS: ^r7711 LT SANITARYNO. APPLICATIONSUBMfITALDATE
UNIT# LOT# \ �Ia��
OW S AMB: �" PHONE- CONTR CTOR' E: LIC NO.ikoqgNIC \ CONTROL#
i�bV f
ARCHITF.CUhNGINEEK: LIC NO: ADDRESS: &[Q(La
D I ❑
it
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MEC
PERMIT ISSUANCE `� lr.�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �T J`O4B DESCRIPTION
KZ Thereby affiraaffusionnot I 3mlicensed Buinessaroviaionsvon,Cost, (commencing mmrncing with Lpff �{pV
�O ion tall farce�nI cffttt�uion 3 of Ne Business and Professions Code,entl my license is in PANELS
r�U License Cl s Lie.# I UP TO 260 AMPS
r�z�s6y Date ,y_ Contractor jCHkM ODOM Gclrl 201-1000 AMPS
Z O o,Z ARCHITECTS DECLARATION OVER I OOO AMPS SQ.FT.FLOOR AREA $6Q.FT.
O L,.-G 1 code r.unA my plans shall be used u public records.
P�2�ly SIGNS ELECTRICAL
K 7 Licensed Professional
KIyU OWNER-BUILDER DECLARATION SPECIALCIRCUITIMISC.
'O a 1 hereby.flim That 1 an exempt from the Comunmrs Liceme law fm the
W 3 O y following mason.(Section]031.5,Busimue snd Prof amiocs Code:Any ciry oreounry TEMP.METER OR POLE INST.
y which requires a permit to construct,alter,improve,demolish,ou repair my structure
priormio iss...ce,alsorequires the applicam fnsuch permit to file a signed statement POWER DEVICES
UJ C p that be is licensed a pum d to the provisions of He Contmcmr's License Law(Clupter
'p2=l .4"9(commencing with Seetmm7000)of Division 3 of the Business and Profession Cade) SWIMMING POOL ELECTRIC VALUATO/NF
„y or that he is exempt Nemfromand the basis for the JleBcd exemption.AnY violation of DDTLETS-SWITCHES-FIXTURES I 1 s1 vO
Section 7631.5 by any applicant for apcmit subjects the applicant viedvil penally of lr
S.O as more IBM Eve hundred dollars(5500). Epw
NEW RESIDENTIAL ELECfR _SQ.FT.
❑ I,asownefofibepro any,ormyemployeeswithwagesastheirsolecomMnsation, STORIES TYPE CONSTRUCTION
63— will do he work,and the$net=is not intended or offered for We(See.7014,Business
and Professions Code:The Comfucmr's License Law does not apply to an owner of
property who ballistic improv.Hereon,and wh0doesmsh w.&himself.,through Ns DEC.GROUP RES.UNITS
n employees,provided that such improvements we not intended or offered for sale.If.
however.the building or improvement is mold withinane yesrofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,uownerofaepmKdy,amexclusivetycontractingwitM1licevWconumimto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Construct the project(Sec.7004,Business and Professions Code:)The Commicmrs
Licenveaw doesnot apply manownerofpropeny whobtildsorimproves Herron,and PERMIT ISSUANCE
whoconuacts for such pmjens with acontmcmr(s)licensed Forstmann the Contranors ALTER CA FEE SUMMARY
License Law. ( 7
❑ 1 am esempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OLITSEDEMPS
SANITARY Y N
Owner Date DRAINS-FLOORROOF. COND. RECEIPT#
, , ,
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX Y
❑ I hereby affirm that l have a cenifmam ideanunOoself-insure,0racenificamof FlXTURPS-PER TRAP RECEIPT#
Wofken'Compenutionlnsuremeeoracenificdcopyt mof(S ,38W,UbC.)which PARK FEE YN
covers ell employee's under this Permit. GAS- .SYSTEM- 4 OUTLETS RECE p
PolicyM BUILDING DIV ION FEES
pany
0 Cartified copy is M1<reby famished. -GA EA.SYSTEM (L
-OVER 4A) PLANCHECK FEE
Cert
❑ Ccnified copy is Bled wiN Ne ciry inspection division. EASFIINDUSTRL WASTE INTERCE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 6REASETRAP SOILS PEE
COMPENSATION INSURANCE
I'Mism,tion need not be completed ifthe pearl is frrone hundrMdollws(510() SEWER-SANITARY-STOR EA.2'FT. ENERGYFEE
or less.)
Icenifyaanin@eperfmmeamof Neworkforwhich Nispermit is issud,l shall WAITER BEATER W(V
not employ any person in any manner so as to become a-,--.m the Workeri PAID
ZComperwition Lewsof Cabromia. Dam WATER SYSTEMTR ate Rtteipl#
Applicant
z 0. NOTICE TO APPLICANT:If,after makinglbia Certiecam of Exemption,you should NEW RESIDENTIAL Mg. SQ. . TOTAL:
Fy became subject to the Workers Compensation provisions of the Labor Cade,you must
a ; forthwith comply withsuch provisionsardo.pentrat shall bedeemed invoked. RU I FEE ^a
aQ CONSTRUCTION LENDING AGENCY SEI 1lfzb
Vz 1 hereby affntm than,Nem is a corauwcdom lending Meng for the perfomunce of GL`ECIRIC FEE
O the work or which this permit is aimed(Sec.3097,Civ.C.)
Iander'a Name
F Lender.Address QTY. - CHANICALPERMIT FEE PLUMBING Mf
V I sonify thin I have read Nis application end ante thin the shows infonermian is MECHANICAI FEF.
7" LT7 comet legrecmcomply with Bit city and county ordinances and sum laws rdatiagm PERMITISSUANCL
V) building conewcuon,and hereby authorize mpresenutiver ofthisciry men in.pont
L) z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCD NTAX
(We)agate m save,indemnify end keep LI Cliablties,' gmrnu,cosusndaa 'car C R HANDLING UNIT(TO IO.WOCFM)
e of the gmnning of this
AIR HANDLING UNIT(OVER 30,000CFM)
Signature f a
plic / ontracmr Dam EXHAUSTHOOD(WIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100,001J BTU) Rtteip
Dunt t#
Wil mapplicard"future building occupant tumor handle bamrdous material HEATING UNIT(OVER 100,000 BTU) TO
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section25532(a)T
0 Yea ❑No
VENTILATION PAN(SINGLL RESID)
ISSUA14CE DATE
Will theapplicantorfmure buildingaccupaamuequipmet will whichmin BOILER-COMP(311P OR 100i"BTU) Fq p
DistrictT C
holumous air conmmirums as defined by the Bay A.Air Quality Mane comnt 4 BOILER-COMP(OVER 100,000 BTU) OF v
11 Ys' El No NEW RESIDENTIAL MECH. SQ.FT. ` `• O 79,Y0
J /9 4
1 have mad the havNous materials rtquiretanu under Chapter 6.95 of the f7
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that Y
ifthebuildingdoes not currently have Amount.that it is my msponsibiliry vicinity the Lvrr
occupant of the requimmenu which must be met prior in issuance of a Certificate of
Occupancy.
Owner or authorized agent Data
ISSUED BY:
OFFICE