27650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPFRTINO B ILUJN'i,I.LbUt Ist PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 27650�C [�O
BUILDING PRoJRCf IUENI IFICA'1'ON v J
BUILDING ADDRESS: I ���� ' I�� ,Tg /� CA, SANI'T'ARY NO. APPLICtit DON SUBMITTAL DATE
OWNER NAME, I'i IONH: CO ACTOR'S NAME: IC NO:
V N/C CO k
�AR TE r GINGEN: LIC O: A D +SS: AV ❑
CONTACT: PHONE: QTY. ELCCTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE �R;` El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz Iherebffi
yarm that l am licensed under provisioraaft7hapterg bormacencing with
WOO Section 7")of Division 3 of the Business and Professions Cade,end my license is in PANELS n ae
Fat UF- ra0f,rce and et t. / ,re{
< la" Licenu Chis Lic.pqa" ((� UPT0200AMP5 Y
Fly Dae �Crrmmxror P}I 201-Imp AMPS f
z Or`�'i,z ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA E/SQ.fT.
C Z—0 I undersand at,plans.hot[seated m public records. A
F•rn F W SIGNS ELECTRICAL !+i
ES
NN
fe
Liceed Prnniomd
66 yy, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. F
d0 F 1 hereby offing that I am exempt from the Contractor's License Law for the B �on
tz131r-rn follawingremon.(Section 7031.5.Busiarm add Pmfessimet Code:Anycityarcounry TEMP.METER OR PULP.MST. x7a7
�o" which requima a permit to consuud,alar,improve,demolish,or repair any stmemre y
yy t0 its issuance.al so the applicant fersuch Permit file a signed POWER DEVICES I ))ryU
<� prior requires PP perm gLa (Jt LUrtn
�• op thatheislicensedpursction theProvisionsof the the Bmnors license Low las Corer
at' 9(dr,he istdgwith Sebtion7000)of bisisian]ofthe Businmsmd.Artyinna Code) SWIMMING POOL ELECTRIC VALUATION
t,_rn
torthion 703ex hyinlyrl rebonedurn fthe basisfar the is thedeaemption.Aryl cion of OUTLETS-SWITCHES-FIX'T'URES /� n
pz¢ Section Ill.
dreddo]].Dpemritsubjecatheapplicannoa<ivilpenalryof
nm mart than five hundred dollen(E5110).� NEW RESIDENTIAL ELFCPR S .19'. {/x xJ p�pq ❑ I,a.ownernl theproperty,nnnyemployeeswith wages a.theirsolccompensntinn, Q STORIES TYPE CONSTRUCTION
will do the work,and the stmemre is nor intended or offered for We(See 7044,Business I
and Professions Coale:The Contractor's License Low does oat apply to an owner of
properly who builds or improves thereon,and who does such work th nceelfor through his
n employees,providedthm such lmpmvemenns are not mundedoroffered formic,If, DEC. RES.UNITS
however,the building or Improvement is mldwithinine year ofcampleion.theowner. AI
builder will have the burden of panting that he did not build or improve for purpose of
c 1
mkJ. QTY. PLUMBING PERMIT f: FLOODZONE APN
❑ La theprject(S 70r ,,Holmes.
A D
sawn the project(Sec.oano Business and Professions Cade:)The Contractors PERMIT ISSUANCE
License tract does not apply moo fth ac of property,whnsed pl m improves Norton,and
Licerm Law.lin such projecawithenmhanur(a)IiccnseJpursuum turbo Contractors ALTER DRAIN License Law. EE SUMMARY
❑ 1 em exempt unJerSa. ,B&P C for thio roman BACK FLOW PROTECT.DEVICE O
_ Owner Dore oNRARYs RECrwil N
DRAINS-FLOOR.RODE.ARPA,COND.
WORKMAN COMPENSATION DI3CIARATION SCHOOL. X t C)'I NIBfs��,G, -
/❑ Ih'Connuramthat lhave ateriveaneofcomtheree (Seen to sure,ora 0.1-ab .),hicf MIXTURES-PERTRAP R"""'"
Workers Compensanion lnaumnce nracertified edgy thermf(See.3800.Lab CJwhich PARK FEE Y
,overalPolicy NII employ. qt a=i`9.S' BUILDING DIVISION FEES
AA --II'' MS-EA.SYSTEMAINC.40UTLETS
Company Is GAS-EA.SYSTEM-OVER PLANCHECK MEF.
❑ Cenifi atopy ifiledwith thec yinsparion Division.opyti/ �S/ GREASEANDUSTRL WASTE.INTERCEPT OR GRADING FIM
CERTUICATE OF EXEMPTION FROM WORKERS' /V GREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is one hundreddullare(EI00) SEWER SANITARY-STORM FA.2001T. ENERGY FEE
to leas.)
I cenify that in the performance ofthe walk for which this Permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the WorkersPAID
z Compensmnla
iorwaof Califnmin. Date WATER SYSTEMrrREATINO Data Receipt
Applicant
Q C NOTICE TO APPLICANT:IL after making this Certificate of Exemption. should NEW RESIDENTIAL PCMB. SQ.FE
8 r you OTAL:
become mhj¢n 1.the Workers Compensation provisions of rhe Labor Code,you must
a , forthwith comply wi@such provisions or this permit shall he deemed revoked. BUILDING FEE
Z CONSTRUCDON LENDING AGENCY SEISMIC FEE
I herebyaffimrthal here iso cnnscral leadingagency for Be,perforrmnbe of 'TOTAL: ELECTRIC FEE
V O the work for which this permit is issued(Sec.3097,Co.C.)
'Lenders Name PLUMBING PRE
Leasers Address QTY. MECHANICAL PERMIT PER
1 cenify that 1 have rad this city
and county
and store that rhe etatee information
ng is
�•' a burred.Iagree mcomply herhall yindyand counvernal waft is nam lawsreadingupon the
PERMIT ISSUANCE MECHANICAL FF.E
U' rn alsocangbonsmad property
herinitia indicates,apses. vesof Chia cityto enter upon the
V aMv(We)igree prove.indemnify add
keep
ALTER OR ADD TO M[CII. CONSTRUCTION TAX
(We)agree nt rove,indemnity expenses
keep harmless the Cityco Criterion ageism
liabilinies,judgmena,cosa and expenms which mayin anyway acemeegoinat mid City AIR HANDLING UNIT(TO 10,0110 CIM)
in consequence of the granting of this pemrik AIR HANDLING UNIT(OVER 10,0011 CFM)
Signature of Applican4Cammctor Dare EXHAUST HOOD(W/DUCE,
PAID
HAZARDOUS MATERIALS DISCLOSURE II HATING UNIT(TO 100,000 BTU) Data Receipt N
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.00d)BTU) T L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilcalth and Safety
Code,Section 25532(e)7
❑Yea PN. VENTILATION PAN(SINGLE kILS10)
Will thedpplicant nrfuturcbuilJingcecupam useequipmemnrdcvicca whichemit
BOILER-COMP(31 IF OR 100,000 BTU) ISSUANCE DATE
bamrdous air connotations m defined by rhe Bay Arne Air Quality Management BOILER-COMP(OVER lal,000 BTU)
Diff ict?
❑Yes 5tI1 No NEW RESIDENTIAL MECH. SQ.Ff.
1 hove read the fety Cohumore,mations 5505.25533ocapdammemunder 34, 1 to erst rd the
California Ileahh&Safe
Code,SCCllarrr 25505.2553]and 25334. 1 unJemm�J ohm
if the building does not currently have a rearm,that it is my responsibility to notify the
occupum of rhe requirements which must met prior m issuance of a Cmifinn of
Occupancy, t /
Owner arumhonte agent one TOTAL: ISSUED B .
OFFICE