27258 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - n ILVI, i.UFTFRICAL PERMIT'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MRCHANICAL n 7 n C O
RI111A1NG PR(1JECT IDF.NTIh'ICATION L G J o
BUILDING ADDRESS: �s //�� {g �� ` SANITARY NO. APPLICATIONSUBMITTA. TE
• ^N UNIT is LOT#
OWN .' AM.: PII CONTR GR'S NA LIC NO: �L
70q= alim,i6 r� N/C CON3ROL#
�ARCHITECT4i GINEF.R: LIC NO: ADDR ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECIj
El El El ISSUANCE L—r`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nmz I hereby affirm that l am licensed under previsionsof Chaparr)mommenciagwith
�00 Section 7")of Division 3 of the Business and Professions Cade,and my license is in PANELS
W W C fall force and effect.
F ZUy UUP License Class Lic.# UPT02WAMPS
ot=y Date Contractor 201-lots)AMPS FLOOR AREA S/SQ.
FT.
Z0,A_ ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.F
O Z'-'G I understand my plans shall be used as public records.
y vl SIGNS ELECTRICAL
4 Licensed Profession.]
L,eo'
OWNER-BUILDER DECLARATION SPECIAL CIRCIIIT/MISC.
iqp,�(dO y V Ing me o (Se that 1 oro exempt from the Enures Co License Lew for the
following mason(Section construct,
Business and ova,de ism Code:Any city m county TEMP.METER OR POLE)NST.
which requires a pnnit to constrvct,alter,improve,Demolish,or reWir any arvcturc
f N�� priormisissuance,almm,uirea the applicmtforsuch pmtiuo fileesignW sutemrnt POWER DEVICES
oG <0 that he is licensed pursuent to the provisions of the Contractor's License Law(Chapter
a4o�' 9(commmciag with Section 7")of Division 3 of the Business mD Professions Code) SWIMMING POOL ELECTRIC VALUATION
y orthat he is exempt herefrom and she basis for the ollegW exemption.Any violation of
F.3 Q Section 7031.5 by any applicant for a permit subjects the applicam to.civil pnalty of OUTLETS-SWITCHES-FIXTURES
K � nm mom than five hundred dollars(SSW). N13W RESIDENTIAL FICCTR _SQ.FT.
❑ I,asawneroMeprepny.ormyempl eesw wegesmtheirsolecomlwnsation, STORIES TYPE CONSTRUCTION
willdothework,udtheswmureisnotin ndedoraf dfmm1a SacJ(144,Businesa
trod Professions Code:"a Commcmr License Law J not apply to an owner of
proprtywhobuildsor imp roves Nerve lend whodcesauch rk himselfnr through his
OCC.GROUP RES.UNITS
owneroployec¢.providW that such i ovemerimmenotmen or4mord fors.]..If,
however,the building orimprav tissold withinone yourofc pldiontheowner- - TOTAL:
builder will have the burden of pr ing that he did not build cr imp ve for purpose of
s0QTY. PLUMBING PERMIT ITE FLOOD ZONE APN
❑ hmownerofthepropn amexdwivelywnvact ing wird licena nvunnn to
onswct the project(Sec.T ,Business and Professions Cede:)The ntmmors PERMIT ISSUANCE
License Law doe.rot app, o arm prOpnywho builds orimpmves th ,and
whecommrtsfmsuchp ars witheconvnctor(s)IicenseJ putsuanuothe Cam cror's AL9LIE-DRAIN&VGNT-
License law. WATER(EA) FEE SUMMARY
❑ leases. rider Sec. ,B P C for this res n BACK FLOW PROTECT.DEVICE TDF S
SANITARY YN
Owner RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPCNS ON DEC SCHOOLTAX Y N_
Ibercby.Toren thetlhaveacenifcme CqPPsem to se ru<enificate of FIX'TIIRES PER TRAP RECEII'1'M
mkers'Compnwtion ireuraneeoru can m cdpy thereof at. O,Lab CJ which PARK FF.E Y N
coven dlemployee's ender thi¢per GAS-EA.SYSTEM.I INCA OUTLETS RECEIPT#
icy# BUILDING DIVISION FEES
Co Y GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECKFEE
❑ 'fied copy is hereby fumt
❑ Ceni Jcopy is Bled w' by ms division. GRP.ASBgNDUSTRL WASTE INTERCEPTOR GRADING FTiE
C' TI A FMI FROMW KERS' GREASHTRAP SOILSFEF.
PENS TIO INSURANCE
(Thissectionnce of c pleted,fthepernitisforo ehundrWdollars(SIW) SEWER-SANITARY-STORM CA.2WFT. ENERGY FEF.
or loss.)
Icenifythatintheper man ice ofthe work for which ispermitisismadIshall WATER HEATER W/VENT/ELECIR
not employ any person in a unner so as to hero subject to the Workers' PAID
Compnsatim Lawaof C.Iifurrin tc WATER SYSTEMMEATING Data Receipt#
z Applicant
O NOTICETOAPPLICANT:ILit ing this Cando,Ie of Exemption,you should NEW RESIDENTIAL ELME, SQ.PC TOTAL:
(p became subject m the Workers Comps ion provisio of Ne Labor Code,you must
from vith comply with such Firestone;or th unit s.11 be deemed revoked. BUILDING FEE
kTl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the prrfmmence of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
OF Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify Nat 1 have read this application and auto that the above information is MECHANICAL FEE
W correct. l agree to comply with all city and county ordinances and shot laws reluing to PERMIT ISSUANCE
F^ V) building construction,and hereby authorizerepoeaenivives ofthis city mcnmrupon the
V (n --,.-..,--..ONTAX
7 above-mcmioned property for inspection purposes. ALTER OR ADD TO MECH.
A (We)agree to save,indemnify and keep humlest the City ofa nine da
n
M�d'ities,judgmems.egloandexp vhichmayinmywi ecs�u� ty AIR HANDLING UNIT(TO I0.W0 CFM)
yucnId ) asce nfthemmidGnft -aper sit. 1
AIR HANDLING UNIT(OVER 10,00)CFNI)
NI'dausiric,ApPhearia"coractor Dem EXHAUST HOOD(W/DUCp PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Date Receipt
Willme applicant orfuture building eocupattt atom ar handle hazardous materialHEATING UNIT(OVER 100,"BTU) TOTAL:
as defined by the Cupcnine Municipal Cade,Chapter 9.12,and the Health and Safety Ik
Code,Section 25532(.)7
❑Yes ❑Na VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will Nea licanmrfuturehuildin occu .rims. BOILER-COMP(311P OR IW,fss)BTU)pp g p equipment unlit Mannaghemh PAID w I D
hazardous air contaminanu as deGrtW by,he Bay Aree Air Quality MuuBemrnt BOILER-COMP(OVER 1M,000 BTU7 1� /Y
District?
l
Cl Yes ❑No NEW RESIDENTIAL MECH. � �O� m 9## �e�
1 have read the hazardouste
rmammals requirements under Chapter 6.95 of Ne 94
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that as if the building does not currently have a tenant,Nm
at it is my pC,•!Y
onsibility to not Ne {a I I Vr I/Urtl'(IIN001- -0 �
occupant of the requirementa which must be met prior to issuance of a Certificate of
Occupancy.
Owner or aethodeed.gem Data ISSUED BY:
OFFICE