27969 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - EtiF PERMITNO.
APPLICATION/PERMIT PLUMBINGROJECTF:CHANIFIC 27962
BUII,DINf,DIVISION BUILDING PROJECT ID4:NT14'ICATI(1N
BUILryNO dbll$5;,� SANITARY NO. APPLICATIONSUBMITTAL DAT
l1/VI�p :J(JS/' ff IWITM LOTM -�
OWNS S E: PHONF,: —7-k7
7� NTRACI'OR'S NAM[: LIC NO: N/C CONTNTROLIf
• A ITECf/ENGINEER: LIC NO: / ADDRESS: ❑
CONTAcr �/ PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
y / 3 PERMIT ISSUANC.Ft BLDG ELE PLUMB MECH
2.YJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm that l am licensed underprovisionsmChapler9(commencing with
PJ00 Section 7")of Division 3 ofthe Business and Professions Code.and my liceve is in ppry
CUu full force andeffml.
pQ.,Z.m License Clues Lic.# UPT0200AMPS C e—c. ,
vs?y Date Contrectm 201.1000 AMPS
,o,Z ARCHITF,LTS DECLARATION OVER)MAMPS SQ.Er.FLOOR AR II $/SQ.FT.
OZ—p l understand my plans shall be used as public records.
FnL:WSIGNS ELECTRICAL
<Y7, Licensed Profusianal
KQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
X is. 1 hereby affirm thin I am exempt from the Contractor's License Law for the
tL 3 m in following masa..(Scaler,7031.5,Busmesa and Professions Code:Any city.,...If TEMP.METER OR POLE INST. /7
F k'0 g which requires a Permit to consumer,alter,improve,demolish,or repair any structure C
C� � priorto its issuance,also inquirePermit s the applicant Permio file a signed statement POWER DEVICES
,%<0 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapser
ddp 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC
W=oe or that he is exempuhercfrsnnmdthe basis for therdlerged exemption.Arte,mlmmird' VALUATI0
FZSection by any applicant for a permit subjects the applicant macivilpenNtyof OUTLETS-SWITCHES-FIXTURES O D
5E<O not more than five hundred dollars($50%
Cts ❑ Lasovacrnfiic n NEW RESIDED ALELECfR _SQ.EJL
props y,ormyempinyees with wagesactheirsolecompert afion, STORIES ECONSTRUCTIO!
y3— will do the work,andthestracture isnot intended oroffeml imsale(Sce.RNA,Business
and Profcslon.s Code:Tie Contractors License Law does not apply to a owner ofown
property who builds or improvesthereon.and who does such work himseu mountainhis
employms.pmvideA auuchimpmvementsmenwiniendMmoffemdforsale.If, / f^, OCCG O _ HES.UNITS
however,the buildingm improvement is.sold within one yeafofcimplenon,theowner- V. TOTAL: �,W P/y
builder will have the burden of proving thin he did not build or improve for purymu of
Esa .).
L as ownernf the propeny,amexclusively contracting with licensedwatramorsto QTY. PLUMBING IT FEE FLOOD ZONE APN
< el the pospsO(Sec.)OTA,Business and Professions Code:)The Contractors
License Lawdocsntn apply to an ownerofpfopeny whobuddsor improves thereon,and PERMIT ISSUAN
whoesmtmcaforsuchprojectswithacontmdor(s)licenudpursua Bothe Convector's
License law. ALTER-DRAIN ENT. ATE-R(EA) FEE
❑ I am exempt under Sec. B&P C m this reason BACK FLOW PROSE .D V OUTSIDE FE
SANITARY Y SCHOOLTAX
0 D - RYECEIPT_N
p
co WORKMANAN COMPENSATION DECLARATIO .J. FLOOR,ROOF,AR O
DRAINS
ElIhereby affirm that l have a certificate ofcoaseat to self-insure,or a certificate of FIXTURES-PER TRAP BF.CE
ITnsIPT s1
Workers Comation Insurance or a certified copy thercnf(Sce.3800,Lab C.)which PARK PEE y ry
covers all employee's under this permit. RECEIPTp
Policy X GAS-EA.SYSTEM-1 INC.A OUTLETS
Company BUILDING DIVISION FEES
❑ Cenifedcopyishembyfumished. GAS-EA.SYSTEM-OVER 4 HAJ PLANCHECK PEE
❑ Certified copy is filed with the city inspection division. GREASE/INUUSTRLWASTEINTERCF.PI'OR GRADING FEE
CERTIFICATE
OMPENOF XTIONINFROM WORKERS' GREASLTRAP SOILS FEE
COMPENSATION INSURANCE
(Ebis,section neWnotbecompletad ifthepemtitisforonehundreddollars($iW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify that in the perfilmwnce ofthe work for which this Permit is issued,l shall WATER HEATER WryEN/ELECIR
Eased not employ any pon in any manner as as to become subject to the Workers' PAID
Z Campensanau LavaafCaOramia. Date WATER SYSTEM?BEATING
Q Applicant Date Receild#
z 2 NOTICE TO APPLICANT:If.after making this Conificam of Fiempuon,you should NEW RESIDENTIAL PLMB. SQ.EL
E" h become subject to the Workers Compensation provisions of the Labor Code,you most TOTAL:
C4 ; forthwith comply with such Provisions or this peman shall be deemed revoked. EE
1 Q CONST RUCTION LENDING AGENCY
—) Z 1 hereby affirm thin there is a canswction lending agency for Bob performance of
U O the work for which this petrnit is issued(Star 3097,Civ.C.) TOTAL:lenders Namc 0 Lenders Address QTY. MECHANICAL PERMIT FEE E1 cenify that 1 have read this application and sme,that the above information is
GW.. sorest. lagr«mwmply with Vl airy arW county oNivnttsand emu laws relating to PERMIT ISSUANCE IZEV) building construction,and hereby authorize representatives ofthis city teener upon the
U Z aMve-mentioned property for inspection pufposev. ALTER OR ADD TO M[CH. ION TAX
(we)agree to rave,indemnify and keep harmless the City of Creasman against
liabililic,judgments,socis and expenses which may in any way accfue against said City AIR HANDLING UNI'I'ITO I OM CFM)
conupy�cc oftM1 ~ng of this intoes! I, /�//�
/Jyj�/ Yilon..-c.iv�.r— J AIR HANDLING UNIT(OVER 10,00)CFM)
Sigardure of Applicanuummector ac EXHAUST HOOD(W/DUCID / Zfi-_ 609
PAID / V GS
HAMRDOUS MATERIALS DISCLOSURE If UNIT(TO IOO.W=BTU) Date Rccnpt pW ill the applicant or future building occupant store or handle haconsho s materialm defined by the Captions Municipal Cade,Chance 9.12,and the Iicalth and Safety HEATING UNIT(OVER 10TOTAL: JCode,Section 25532(a)Y 00
❑Yes ❑No VFMILATION PAN(SINGWill theapplicaat or future buildingmcupantuuauipmentordevices whichemit BOILER-COMP CRIP OR 1ryryISSUppANCEnnDATE
AIM hazardous air cnmaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOtr Psk6YUi mea ❑Yes ❑No NEW RESIDENTIAL MECH
I have cad the hmadous materials mquiremen¢under Chapter 6.95 of the APR 1 1995
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building dins not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Cenificae of CII I Vr V Ur r m i INU
Occupancy.
Owner err authodeed agent nam
TOTAL: ISSUED BY:
OFFIC