27855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .' ' - PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27855
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO. APPLICATIONSUBMITTALDATE
v03Fj6 RadetmeS UNIT#0 & /,/am
O
OWNERS NAME PHONE: CONTRACTOR'S ME: LIC NO: N/C CONTROLit
Cll514 /.an 11.007es 9n et'. a (C u9ner
ARCH[HICT/ENGINF.ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
�� QTY. ELECTRIC PERMIT FEE
/•-e a Cc a,4 6/'I �J�ys PERMIT ISSUANCE BLDG ELECT PLUMB MECH
V/iI/ ((y Ip( br
LICENSED CONTRACTOR'SDECL T APPLIANCES-RESIDENTIAL JOB DESCRIPTION 111
q tYz Ih7")mfrnthat I amlicemsedinss and rifesion,Code ancommencing with /� //'�1L
[v10E Section]000)of Division 3-fine Business and Professions Code,end my licence is in PANELS S FD `�— f'
tFy
VE full force and affect.
G'�,� License Class Liv.q v UP TO 200 AMPS
of}y Data Contractor. 201-1000 AMES
zOwiK ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O zt4 m 1 understood my plans shall houses]us public records.
rj J SIGNS ELECTRICAL
W L¢enseJ Professional
OWNERBUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O a E I hereby..(Se that 1 am exempt from the Coninews Ca License Law for the
following reason.(Section 70315.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST, Y7J17
which requiresamor permit construct,elkm improve,demolish,or repair any sweture
CN¢� thadhe its issuance,elsoreyuires the applicant for each permit toLice se La stohapter POWER DEVICES
tat Cap thus he is cnw pursuant m tha provisions of the Commoner's License Lew(Chapter
LLWoo' 9t(commencingthat
hiswis therefrom
an the Division 3 ofthe Business and Professions Chile) SWIMMING POOL ELECTRIC VALUATION
y1�y onhatheisexempftherefromand the basis for the alleged exemption.Anycivil
of s, —�
Section]031.5 by any applicant fora permit subjects the applicant m e civil penahy of OUTLETS-SWITCHES-FIXTURES
Onot more than five hundred it.])..($500).
❑ LosownemDhepstruct,ormyemployediewlwagesmthe(SelecompBasin n, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will dome taisurk,ands TheCureiators License La a doesed net apply Z,Business
and Professions Cade:The Contractors License Lew rices not apply lf an owner of
property whobuitmorimproves thereon,and w tsdoessuch work oroffeforthrough his
own employees,p building
or improvement
prove impis vemsold within
ne iour ofedoroffered the own If, OCC.GROUP RES.UNITS
however,ill howethe order offinemissoltledid one your of completion,the f
builder will hnve the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,as owneroflhe property,amexclusively contracting with licensed contracbrsto QTY. PLUMBING PERMIT AEE FLOOD ZONE APN
construct the project(Sec.]094,Business and Professions Code:)The Contractor's
License Law does notapply to an ownerofproperty whobuilds orimproves thereon,and PERMIT ISSUANCE
who commensfor such projects with a conwamr(s)licensed pursuant ttede Convector's
License Law. ALTER-DRAIN At VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSID ES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPfN
• - WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IherebYpernmohmlhave aeortScerteof eomxnuncof(Sec.311 ),Lm
C.)e te ofwhich
FIXTURES-PER TRAP RECEIPTM
Workers Compensation Insurance oracertified copy thereof(Sec.3Ba),LebCJwhich PARK FEE YN
covers all employee's under bis permit GAS-F.A.SYSTEM4 INC.4 OUTLETS RECEIPT M
Policy k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKFEE
1:1 Cenifer copy ie hereby famished. O$ A
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR
GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section readout bewmpleted ifthe permit is Receive huntlrcAdo11ars($100) SEWER-SANITARY-STORM F.A.201
orleas.) ENERGY FEE
I certify that is the performance ofthe work for which this permit is ismask I shall WATER HEATER W/VENT/ELECR
not employ any person in any member so as to become subject to the Workers' PAID
z CCmin on L
o tiaws of Califomia. Data WATER SYSTEMnREATING licant — Date Receipt N
O 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V] become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
Y r
Z
CONSTRUCTIONLENDING AGENCY SEISMIC FEE r
Irk for whaffich
is Eamon
is acued(Sec.3on le Civ.gency for the pertormence of �6 r 7.2
L) O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
w U ndm's Name
Q U LeLenders Address Q'fY. MECHANICAL-PERMIT FEE PLUMBING FEE
I certify that I have read this application county
r in that the above infomtating is MECHANICAL FF.F. `1'
C0.O 161,
Goren. lagree tocompld withal leirymeampand ntyrurdivncesand cute enteruatingm PERMIT ISSUANCE 1
above-mentioned
on.end herebyamhodurepresenmtives of this city toenmrupon the CONSTRUCTIONTAX
L) 7 above-mentioned toxic.yformnify for purposes. ALTER OR ADD TO MECH.
F7 (We)ag toxic indemnify and keep hamlesa the City of Cuperino against
liebilities,j ments,costs an penses which may in any weyecerueageinsts'd Ciry AIR HANDLING UNIT(TO 10,000 CFM)
in cause ceofthegra ft
his Permit.
/O AIR HANDLING UNIT(OVER 10,000 CFM)
re of Applicant/Counac r Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) r Date RwelptM
Wi 11 the applicant or future building occupant store m handle hacadous..,arias HEATING UNIT(OVER t00,hdO BTU) TOTAL:
as refund by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Suction 25532(a)Y VENTILATION FAN(SINGLE RESID
❑Yes ❑No ) OOD�
BOILER-COMP(3HP OR I W,M)BTU) ISSUANCE DATE
Will the oexaccrnt or icandsfuture bullring by the
•"Ya, nBay Arco enmrdeviceswhlchemit 0— P�
C]
hazardous air contaminants as reined by the Bey Arco Air Quality Management BOILER-COME(OVER 100,000 BTU)
Yes ❑No NEW RESIDENTIAL MF.CII. SQ.FT. OCT 9 1f 1AaDad a hazardous materials rcquinure under Chapmr 6.95 of the �'' Ur t Safety Code,Se ions 25505,25533 and 25534.1unit t dthat UUsnot current atenam,thatitismy camebili tm tify the
requlremen ch must be met prior to issuance a C izedagent Data TOTAL: ISSUED BY:
OFFICE