27166 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[BUILDING
ITY OF CUPERTINO BIc6INu=llclte'r A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27166
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
ADDRESS: - SANITARY NO, APPLICATIONSUBMITTALDATI
0 pCc Wood t7 UNITM LOT If
WNERS NAME-- PHONE: CONTRACTORS NAME: LIC N(h
ZS-7— 7 YSS WC LUN
TROL#
ARCHI'MCIENGINEEK: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECH
PERMITISSUANCE fd ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL lCY
lhereb ffirm#entero licenseA under JOB DESCRIPTION
qW TC2 Ya pmvisionsons Corer9nd mmecensewish
FOE Section7001and of Division 3.f the Businev and Pmfnsimas Code,end my,license is in PANELS
y�j full force lasellen. 1 J
FZy( Licence Clens Char UP T02W AMPS
Nati Dam E-CTS
2(11-TWO AMPS
oz-mARhall be CTSDEClic me ON OVER 1000 AMPS SQ.FT,FLOOR AREA $/SQ.FT.
O Z I understand my plana shall be usW es public rcnnNs.
F�(=�
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
.°KOy1- 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
rr131'-a following mason.(Section 7031.5.Business and Professions Cwle:Any city or county TEMP.METER OR POLE INST. m I \� r• \ IST, h h II (�j�
y
f-LL which rtyuves a pemdt m comwe,otter,improve,demolish,or repe'v any structure u
Cy%Q2 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
ad 0 p Net he is licensed pursuant m Nc provisions of the Contrvnm's License Low(Chepte •J
p' e(xy 9(comnuncing with Senium?O(p)of Division3of the Business enJ Professions Code) SWIMMING POOL ELECTRIC L 0A
MON
yt 2rA or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES TPF
tKy Section 90315 by any applicant for a Permit subjects the applicant to a civil penalty of DAIS I
2=< not more Nan five hundred dollam($500).
�1p ❑ I,asownerofNe n NEW RESIDENTIAL ELECIR _SQ.Iffy"-
pmpe y,mmyemployceswiN wogeeas Neirsolecompensadon, STORIES TYPE;CO STRUCTION
a villdo the work,and the sometimeisnm mmndedocaffertd fm We(See.]004,Business
and Professions Cole:The Contractor's License Law does not apply men owner of '
pmpcny who builds orimpmves N uch improved crusam ssuchwmk himulfm Buoughhis
wnemployecs,pingor improvement pissuld ntsurenot earrof dmpletiod farsathea e. r- OCG GROUP RES.UNITS
builder ,theavete hu an ofpissolde did not year or mmovefie,Neowne- TOTAL:
builder will have the burden of proving Net he did not build or improve fm purpose of
❑ I,asowncrof Nepmpeny,amexclusivelycontraming wiNlicenadmnnennrs to QTY-1
PLUMBING PERMIT IIiE FLOOD ZONE pPN
ovwa the project(Sec.7014,Business and Professions Code:)The Contractors
License Lawdoes not apply toanowaerofpm n who builds or int PERMIT 3�
pc yw improves Contin ou's Q
U.".who s.,forsuch projauwith econuanogs)licerued pursuant the Contractor's ALTER RA FEE SUMMARY
Littnu Law. IRA)
❑ 1 am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE O S )E
Owner Date SANITARY YN
DRAINS-FLOOR,ROOF,AREA,COND. RECL•IP`r#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iberebyaffim Nat lrLaveacenificuteofconacnuseelF-inaure,oracenificateof FlXTURLS-PER TRAP RECEIPTX
Workers'CornpetmtionlmutancemecerBfiedcopy Nercof(Sec.3800,Lab C.)which t PARKIEE Y_N_
covers al l employee's under this permit' GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumified.
❑ CenifiN copy is file)with the city inspecrion Division. GREASEINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This smtinnneednot be completed if Ne permit is for one hundred dollars($10(ySEWER-SANITARY-STORM EA.200FT, ENERGY FEE
or less.)
I certify Not in the performance of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIR
at employ any person in any manner an as to become subject to the Workers' PAID
z Compemmionlawsof Califomia. Data WATER SYSTEMIMEATING Data Rmeiptp
C) O Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
V) tt
become subject to the Worker's Compensation provisions of the Labor Coda you must '1'O'fAL:
a forthwith comply with such provisions or this permit shall be deemed invoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hembyuffirm that there is a connructiun lending ngacy for the perforrommeaf
C..F O the work for which this Permit is isauW(Sec.31199,Civ.CJ TOTAL: ELIiCIRIC FEE
Lender's Name
O V Lender,Address QTY. MECHANICALPERMIT FEB PLUMBING FEE
1 certify that 1 have read this application and same that the above information is MECHANICAL FEE 1 correct. Iagree mcamply with all city and county.,Jmane.andstam law. to PERMIT
F' Lij building construction,and hereby auNmbe representatives of Nis city to enter upon the CONSTRUCTION TAX
V z above-mentioned property for inspersion ptuposes. ALTER OR ADD TO MECI1.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmvmx,costs and expenseawhich may inany wayacerueaildrut said City AIR HANDLING UNIT(TO 10,000 CFM)
in corfs�uenCe of the grarning of this permit. _
�\v��p AIR HANDLING UNIT(OVER 10.000 CFM)
SngdmeFrf'Appincant7 onhactd t /0&, � EXHAUS'1'HOOD(WNUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,OW BTU) Data Receipt
Will the applicant or future building occupant am or handle haraudons material
as defined by the Cupenum Municipal Code,Chapter 9.12,and the Hea th and Safety HEATING UNIT(OVER IOO,OW BTU) TOTAL:
Coda,Scotian 25532(q?
❑Yes 11 No VENTILATION FAN(SINGLE RRSID)
es
ch
Will the aconta contaminants as
sbuilding by the Bay Auipmcnmuality Marnalemern
BOILER-COMP(3HP OR 100,0A BTU) ISSUANCE DATE
haaardom air canmminenu u tlefined by the Bay Ara Air Quality Manegemcm
Diao-ict? BOILER-COMP(OVER IW. 0 JIM) -`s "•y ElYes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have roadN
the haxaoes materials requirements under Chapter 695 of Nd,
OCT +
e 1994
California I Icahn&Safe,Code,Sections 25505,M533 and 25534.I understand the
if the building does not currently have a arnam,that it is my responsibility to nmiry the n
occupant of the req ammaca which must be met prior to issuance of a CamiBcme of CI I T Vr y V f LTL If Y V
Occupancy.
`• a
Owneraramhoriredagcm Date TOTAL: ISSUED BY: N Vl�
OFFICE