27582 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING ai ...e R ,n PERMrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27582
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
RING ADDRESS: SANITARY NO. APPPLLIICCATITIO�N SUBMITTAL DATE
G r UNTrp LtYTp �' / /, /
C
O ER$NAMONE: CO ACTOg'S NAME: LIC NO: !!ii NT
• L D �A O NIC CONTRDLp
ARCHITECT/ENGINEER: LIC NO: ADD SS:
ujor J
CONTACT: PHONE: Qom. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BL ELECT PLUMB MECH
PERMIT ISSUANCE, El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ClWX I hereby affireathat l am licensed underpmvisionsof@apter9(commencingwitb JOB DESCRIPTION
4100 Section Y(NN)of Division 3 ofthe Busintolnd professions Cexle.und an,license is in PANELS
Fye-,U full force and effect. �/
F ZuI License Class Lic.p�goQelg UP TO 200 AMPS
N<p' Date Comdr rr Zi IlloJ I Q5 Hn
FyZ ARC]IDECT'S DECLARATION 201 100AMPS SQ ET.FLOOR AREA $/SQ.IT.
p0 I underdand my plans shell be used as public record.. OVER LUN]AMPS
1=•to E SIGNS ELECTRICAL
Licensed Professional
a�a6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XC W, 1 hereby affirm that I am exempt from the Contractor's License Law for the _
W 3 a H following a awn.(Scetion 7071.5,Business mal professions Code:Any city mcounty TEMP.METER OR POLE INST.
t�;O; which requires a Permit to construct,alter,improve,demolish,or repair any structure
!(T� pritoitsissuancc,also :mrm
rcyuims mallpiict for inch 1.Men signed statement POWER DEVICES
m
ty tea_ O that he is licensed pursuant to the Provisions of the Contractor's License Isw(Chapter
p•Xo� 9(commcncing with Section'l000)ofDivisionJoftne Business and Professions Code) SWIMMWG POOL ELECTRIC ��VASLUATION
W--rn onhat he is exempt and the Nava Err the al laRed exemption.Any violation of OUTLETS-SWITCHPS-FIXTURES
tK< Section 703 1.5 by any applicant l'or a permit subjects the applicant a civil penalty of
not more than five hundred dollars($500). NEW RfS1U[iNTIAL LIECTR _SQ.FT.
CHo ❑ I,mnwnerofthepropeny,nrmyemployeeswitM1 wages asthciraolecompcnsation, STORIES TYPE CONSTRUCTION
will dothcwork.and the structure is not intendedoroffered formle(Sec.J044,Businnsv
and Professions Cade:no Contractor's License Law does not apply to an owner of
property whobuildsorimprovcsthereortandwhoduassuchwork himselforthreaugh his
oemployees,provided that such improm
veencomenot intendedoroficad f^rsale.If, OCC.GROUP RES.UNITS
howaver,the building or improvement issold withinonuycwefmmplUiogthaowner- TOTAL:
builder will have the burden of proving that he did not build cr improve for purpose of
sale.).
❑ I,asrwmrrnne vrrpeny,am excrosivdyeontracung w;m Eeem,ea commanrstn QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
instruct tlm project(Sec.7044,Baseness and Prorexsinas Code:)The Contractors
License Law does notapply toa enodarofpropertywM1n builds or improves thareon,and PERMIT ISSUANCE
who commas forsuch projects with aconuartmos)licensed putsuanuo the Contractors
License Law. ALTER (EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE, OUI SIDI'FEES
SANITARY Yry_
(honer Data
WORKMAN COMPENSATION DECLARATIONDRAINS-FLOOR,ROOF,AREA,GOND. RECEIITif
❑ Thereby affirm thmlhaveacenificate of consentto uif]f-insinsure.rracenifi<ate of SCHOOLTAX Y N
Fri-PER TRAP RECEIPT#
Wmkers'Compensabon Wumnce orarenified<opy therrof(See.3S00.Lab C.)which PARK FEE Y_N
ors all employee's under this permit. GAS-EA.SYSTEM.I INC,4 OUTLETS RECF.IPI•N
Pooley N' BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER (EA)❑ CenifieJ copy is hemby famished. ( PLANCHECK FEE
❑ Certified copy is filed with the city inspection divisions. GRFASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not b,completed lime penton is for one hundred dollars(SIW) SEWER-SANITARY-SJ'ORM E.2WFT.
less.) ENERGY Fill:
I certify but in the perfommnceofthework for which this permit is issued,l shall WATERHETERW/VENT/ELECTR
not employ my person in any manner so as to become subject to the Workers' PAID
ZCnmpcnsation laws of Califomm. Date WATER SYSTEMTRETING Uarn Receiptp
Q O Applicant
z NOTICE TO APPLICANT:IL after making this Commando of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. .NOTA
F K become subject no'he Waders Compensation provisions f,ha Labor Code,ynu must
Qi 7 fonbwith comply with such provisions or this permit shut l he deemed revoked. BUILDING FEE
y A CONSTRUCTION LENDING AGENCY SF,ISMICFEE `
Z) Z I hereby afPom the them is a construction lending agency for the performance of
V O the work for which this permit is asocd(Sec.1092,Civ.C.) TOTAL: ELECTRIC FEE
Londa,Name
O U lander.Address QTY, MECHANICAL PERMIT FEE PLUMBING PER
I certify that I have read this application and state that the above information is
coned l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL.FEE
F-' i,t building comructirn.and hereby amhorive expcanmtivesofthiscity to=we upon the
V Z above-mentioned property for inspection proposes. ALTERORADDTO ECH, CONSTRUCIJONTAX
(We)agree m save,indemnify and keep harmless the City of Cup gam against
liabodu es,judgmemtscos Bund expenses which may in any way accrue against said City AIR HANDLIN N 010,000 CFM)
in cnnscq� she ling of Nis 't.
/J12-Z7-2r AIR HAN G VERT , )
Sigiodurifild Ap,fielintlCtembacte, Data EXH STHOOD /DU
PAID
HAZARDOUS MATERIALS DISCLOSURE s SCLOSURE LNG (TO 1(X1, ) Date Reccipt a
Will the ap Cupertino
rr future budding occupant store or handle hazardous material
Co Defined by the 32pemino Municipal Cade,Chapter 9.12,and Je Hcaltb and Safety H NIT(O I W.000 BTU)
CNc,Section 255J2(e)?
11 Yea 0N VENTILAT FAN(SINGLE RESID)
Will theapplicant or fmurebuilJingoccupanmxequipmemmdevices whichemit
BOILER-COMPHIP OR 100.0008 ISSUANCE DATE
Innuendoes air contaminants as defined by the Bay Area Air Quality Management B ER-COMP(OVER 100,000 ) A ' D
Dialer! A
❑Yes ❑No NEW R IDEN'TIAL MECH. SQ.FT.
1 have mud the hnrnrdous materials reyuircrmnts under Chapter 6.95 of the DEC 2 X994
California klmJth&Somry Gde.Sections 255(15,25533 and 25534. 1 understand that ,,,
if the building does not currently have a tenant,that it is my responsibility to notify the e�
crpnnt of the rtpuirements which mud h ma prior m issuarec of a CmiG<ate of CI I,� ZINC
occapancy. (.
Owner nr arthonvnl agent Date
TOTAL: ISSUED BY:
OFFICE