27993 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IBEN'1'h'ICAT'ION 27993
BUILDING ADDRESS: � VtStr114PtCT
SANITARY NO. APPLICATION ICAON SUBMITTAL DATE
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CONTACT: PHONE: +rBUILDING PERMIT INFO
QTtY i,'" .ELECTRIC PERMIT FEE BLDG ELECT PLUMB MECx
J 9F&tt;fi,•a
H v j o.% S /o 7�2�(�6� PERMIT ISSUANCE � ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ApPLIANCBS-RESIDENTIAL
O=Z Iherebyaffirm that l am licensed under provisionsof Chspter9(commencingwith JOB DESCRIPTION
�00 Section 7l#l0)of Divisy'�n3ofthe Business and Rafessions Code,and my license is in PANELS ���� �
�do ran taro arta arca<n/L U Z
yyW Licenuyc—lass'�a.+ Lic.# 7 lIP T02W AMPS
ti=vai Uate l" Convaztor . �� 201-IOW AMPS
ZON3 ARCHITECTS DF. LARATI OVER 1000 AMPS SQ.ET.FLOOR AREA $ISQ.FT.
O Z,—pp 1 understand my plans shall M used u public records.
I..rn W SIGNS ELECTRICAL
<Yk:j Licensed Professional
wwm< OWNER-BUILDER DECLARATION SPECIAL CIRCUMIMISC.
xL�4O a U 1 hereby Mr.that I oro exempt from the Contractor's License law for the
Iy 2 a y following reason.(Section 703 L.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
F Orn which requires a permit to consumer.alter,improve,demolish.or repair any awcture
pggpcdT� prior ro its issuence,alsm requiresthe applicant for such Permit file.signNstatement POWERDEVICES
ss"3 C C O that he is licensed pursuant to the proWsicas of the Contractor's License law(Chapter
LL cxx.0 9(mmmencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POO F.LECIR VALUATION
W_m ormau he is exempv ummurn and the,basis for thealleged exemption.Anyviolationaf DUTLEI'$-SWf1'CHES-Fl �—
GSection7W L5 by any oppliuntfor apemtit subjects due epplicanuoacivil pmelry of 22
not mare than live hundred dollars($50(y. NEW RESID , AL ELECTR S .FT. �~v
0 ❑ I.asowneraftheproperty,ormyemployuswithwagesastheirsolecomprnsadon, Q STORIES TYPECONSTRUCTION
will do the work,and the structure is not intended or offered for sale(Sm.7044,Business `\
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimproves thereon.and whoduessuch work himselforthrough his \ OCC.GROUP RES.UNITS
own employees,pnwided thatsuch improvementsarc not intendedoroffered(.,We.If.
however,the buildingor improvement is sold within one year.(completion,Neowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowner ofthe property,am exclusively contracting with liceasedc.humaor to ;Y. ' I PLUMBING PERMIT ` FEE FIAODZONE APN
construct the Project(Sm.7W,Business and Professimu Code:)The Contractors
Licenselawdocomt.pply,...vv erofpmpenywhobuilds orimfou caHereonand PERMIT ISSUANCE
whocontructs farsuch projects with acontractoxs)licensed purunat w the Conwcmr's pLTCR-DRAT B A R(F
Lt..Taw. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far this rcvon N S
BACK FLOW PROTE .DEVICE SANITARY YN
Owner Dow DRATOOF,ARP COND. RECEIPfp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby affirm that l have a carincate ofconsenno self-insure,or a anificam or FI U S RTRAP ECEIPTp
orkets'ComPevationlnsurnmeora mnified copythereof(See 38M.Lab C.)which PARK FEE N
covrGAS-EA. YS M-I IN .4OUTLETS ECEIPT#
PolicyIL N
DIVISION FEES
-Com�^
YfI E��V�� GAS-EA.S TCM-O ER 4IEA) PLANCHCC FE —
t�(:enifiedcopyisher famished.
❑ Cenifiedcopy is filed with the city inspatian division. GREASEINDUSTRI.WASTE INTERCEPTOR GRADI
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOBS FE
COMPENSATION INSURANCE
(Tis section door becomplems!ifthe Paean is foranebumbet dollars($10(h) S ER,SANITARY-STORM EA,2WFf. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELEM
not employ any perm. in any manner an as In become subject m Ne Workers' PAID
,z Compenatio
sn Lawsof Califomix Date WATER SYSTEMIMEATING D a tp
Applicant
�� Q NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
� become subjcctta Ne Workers Compensation pmvisioru.(the Labor Cade,you must r�
1 foMwith comply with such provisions or this permit shell be deemed revoked. BUILDI
[� CONSTRUCTION LENDING AGENCY SEI I
7r I hereby affirm Net then is a wnstruction lending agrncy for the performance of
U O be work(or which this permit is issued(Sec.3097,Civ.C.) TOTAL:U. EL IC EE
Isnder'e Name
0 U Lender's Address QTYt ,MECHANICAL PERMIT FEE PLUMBING
Lkl I cannily that I have reed this application and naw that the above information is yt'°e' MECHANI FEE
Q. correct.l since to comply withall city and county ordinances and grew laws relating to PERMIT ISSUANCE
building construction,and hereby outhoriuwpwsenreuvw of Nis city to enter upon Ne CONSIRU NTAX
move-mentioned property(or ins tion
V "� (WC)o pec purposes. ALTER OR ADD TO MECH.
gram ,indemnify and keep harmless Ne City of Cupertino against
liobilivae jud�sandes i+rhyymwy in any way accrue against said City AIR HANDLING UNIT(TO IQ000 CFM)
nuyue h Veo ting re /��
/—T, AM HANDLING UNIT(OVER IO,glll CPM)
rcof p,1itmVCum.,mr Data EXHAUST HOOD(WIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I(00,000 BTU) Dow Receipt
Will the applicant or future building occupant store or handle hurardous material HEATING UNIT(OVER 100.000)BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I health and Safety
Coda,Section 25532(o)P
1:1 Yes ❑No F.RVENTILATION FAN(SINGLESID)
BOILER-COMP(3HP OR 1 W,WO BTU) ISSUANCE DATE
ardonWill tair co ican menta s building by*0nBay A ipmentQualit Man igeme is R4 p B
"let? air contamiwnr as defined by Ne Bay Arta An Quality Management BOILER-COMP(OVER IW.f100 BTU) f M
rricR ❑ 9
via .
Yea ❑No NEWRF.SIDENTIAL MECH. SQ.Fr. MAY1
1 19Q�js
Hwa V
1 have read the hanrdm mst
oermis reyui...us mom Chapter 6.95 of the vv
Califomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that rs'/r
if the building not currently have a tenant,that it is my responsibility to notify the (fir �,��r�
occupant of the requirements which must o met prior to issuance of s Certificate of �UYGhI ��
Occupancy.
Owner or authariud agent Date TOTAL: ISSUED BY:
OFFICE