27882 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-HLECI HICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27882 O O n
BUILDING PROJECT IDEN'I I FICA'I'ION L o o G
el .DING ESS: W�p Bug.y �V IOTk SANITARY NO. APPLIGTION SUHMfITAL DA'IT3
q_VA F;RSNP: �V� PHONE: TRA{$OR;S;AMF6�� _ LIC 0:
/V
C
t e b NIC CONI'ROT,M
•ARCHITECT/ENGINEER: LIC NO: DDRIStLLg/yO III*rq;j' J('
—
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
SLUG EI.F.Cf' PLUMB MECH
PIiRM11'ISSUANCE 7%F
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL C IITIO
gUCC Thereby affirm Natlum licensed underprovisinvofChepter9(rommencing with mss/#
WOO Smtio hereby
affirm find I am
Businessan visinnssio®Code, (c mmencine wain ppNF.IS R
1e 6'E fullforcem fleet.
NZ41 ts-
License Lic.# UPT02MAMN'Pan, contractor Conoazm, 201-Itlfl)AMPS SQ.Fr.FLOOR AREA S/SQ.Ff.
Z I-; ARCHITECTS DECLARATION OVER I"AMPS
CZ-0 I understand my plans shall he used as pulthe records.
m SIGNS ELECTRICAL
q' LicenuA Profesxionnl
OWNER-BUILDERDECLARATIONthe Cr ATION SPECIAL CIRCUIT/MISC.
1 hereby n.(Section
Se thst 1 am exempt from the Cnmons Co License Law for the
followtKn3ay which iaguiresa Permit
to construct,that.
land ve,demmh,orre Any city or county TI!MP.METER OR POLE INST.
which requires a peanut re construct,ppic improve,demolish,or repair any structure
W YS thionei becu puse. aurequi es the pr visio s at of theuch ContraaiOo file Lice signed statement POWER DEVICES
W �pa 9 at he bronaisl!ceasalpunctionmint 7")of
the Cnnnmmrs License I'mfsomChapter
a eLL 9(cnmmencingwith Section Division 3ofthe Business and.Aryivins Code) SWIMMING POOL ELECTRIC VALUATION
,may onbnthci31.5 btnherel'rnm and the basis fnnhe alleged exemption.Any vinlm!nnof
G Sretinn]031.5 by any applicant l'orapehmit auhjenx the applicodno acivil penalty of OII'1'1,I!'fS-SWITCHCS-PIX'fURES
in more than five hundred dollars($500).
o ❑ 1,mnwnerofthepmpcny,ormyemployeeswi[lhwnga®theirmlecempensaiion, NEWRPSIDPNTIALELECIR _SQ.FT. STORIES TYPECONSTRUCHON
x340 will do the weak. it themunure is not intended arnffetd fersale(SccJ(H4,Bmarees
and Proficesimw Code:The Cnatrecmes License Lew does not apply to in owner of
femperry whobuillsnrimpmvestherean,andwhadoeasuchwork himselfm[ rmithh!s
own employers,provided that such improvements urtnot intended oroffercd for sale.If, DEC.GROUP RES.UNITS
however,the building...improvement is and within one an, fcompletino.the owner- TO
builder will have the hunlcn of proving that he did not build or improve for purpose of
le.).
❑ I.as owner oftheprapeny,am exclusively contracting with licensed emmunrste QTY. PLUMBING PERMIT FEE II,GOD ANE APN
ceashuct the projen(Sec,101 Business and Profusions Code:)The Cnnweu r'e PERMIT ISSUANCE
Lice se Lewdcesnot apply tom nwnerofpropeny whi.mildsoricepmvnthercnn.mJ
who contracts for such projects with acontactm(s)licevd panamtao the Contmnota
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt umkr Scc. ,B&P C for Chir reason BACK FLOW PROTECT.DEVICE SANITARY' OUTSIDE Y I N
Owner Dam RECHIPTp
DRAINS-FLOOR.ROOF,ARIA,C(IND.
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y N
❑ Thereby affnn thmlhuve acenificete of conscm mself inanrc,ern ccnificme ofRECEIPfp
FIX'1'UR0-PER
Wnrkes'Compensmian Insurance or ecenified mty thereof(Sec.3800,Lnb CJ which PARK PCI; Y N
coven all employee's under this penniL l GAS-FA.SY -I INC.40 F.TS �^ RECEIPT.
Policy p BUILDING DIVISION FEES
Company A,SYSTEM-O R4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
[I Catlfied copy is fled with the city inspection division. GRFASH/INDU§TRL INTFRCHP`T GRADING FEE!
CHRI]FICA1'E OF EXEMPTION FROM WORKERSGREASE TRA SOILS TEE
COMPENSATION INSURANCE
(This section need not se completed ifthe permit is retool hundred dollar SHXB SEWER- I -STOR
Al ENERGY FIiIi
or last x 11
I certify that is the perfomance of the work far which this permit is issued, hall W A Wry ' •I.P
net employ my person in nay modal,m u m became subject to the W PAID
Compensationl.nwsuf Califomia. Date ER SY RWR Date Receipt#
Z Applicant
0 � NUI ICE TO APPLICANT:if,utter making this Certificate of Eventb h ou Shaun N W ESIOENTIAL .MB. SQ.PT.
Z r-a Comptil •y TOTAL:
E-' raceme subject the Worker's Compensation provisions offs Labor Cale,you mu
forliwith comply with such provisions or this pennit shall be dttmed revoked. BUILDING FEE
0. Q CONS3'RUCTION LENDING AGENCY SEISMIC FEE
UZ {hereby affirm[Mt there iso constnation lending agency for Ne perfomtuntt of
O the week for which this permit is is,md(Sec.3091,Civ.C.) ELECTRIC FEE /—
Lenders Name
F a PLUMBING FEE Lenders Address Q'CY. ECIIANICAL PERMIT FEE
L) I certify the,1 have mud this application and state that the above intendant
on is
W correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE ,/� MECHANICAL IEE
�^ V) building conetudiimand hereby amhorize representatives ofthis city to enter upon the CONSTRUQI'IONTAX
V z above-mentioned property for inspection purposes. ALTER OR ADD TO MI CH.
(We)agree anni cep harmless the City of Cupcninu against
liabilitiesju ants,mst which may in any wayaccoeagainn said City AIR HANDLING UNIT(TO 10,00K)CIM)
in Co. Ire f,h,gr AIR HANDLING UNIT(OVER ELM CFM)
ignst n[/ n u r Dwe\J EXHAUST HOOD(W/DUCp \ PAID
IIAZARDOUSMATFAfALSDISCLOSIIRE I IEATINGUNIT(TO100,0110W['U) Dote Raeipt#
Will the applicant or future building occupant store o,handle hazardous material HEATING UNIT(OVER 100,(Nq BTU)
1b A
u defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Cale.Section 25532(a)? VENTILATION FAN(SINGLE RI'SID)
❑Yes ❑No
BOILRR-COMPDHPOR 100,(X10 BTU) IS$ NCE DATE
Will[heapplicanm,fmurebuildingcecupanmuequipmcmordeviceswhichemit La Y �
•hazardous air contaminants as defined by the Bay Area Air Qtality Menug[menl BOILER-COMP(OVER I00,(g0 PTU) LjQ�
Disaicfl p
❑Yes ❑No NEW RESIDENTIAL M[CI1, SQ.PI'.
1 have read the hazardous materials requirements under Chapter 6.95 of the Cq! Vr 1995
California Health&Safety Code,Sonans 8505,25533 and 25534. l understand that
if the building docs not currently have a tenant,[list it is my usponsibility to nmify she
occupant of she requiremems which must be,met our to issuance of a Cenifeata of tMIIryC
Occupancy.
Owner or.authorizeJ ngcm Dane A ISSUED BY:
OFFICE