27387 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDINU-LLLUPERMIT NO. H
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDFINTIFICATION
BUILDING AUURIiSS. I ' '' SANITARY NO. APPLICATION SUBMT-FALDATE
11
Y " \ vE- Ave UNITa LOT# _
T3OWNIiF}tirNAME _e� _— PHONE: CONTRACTOR'S NAME: LIC NO:
G/:`/'.IF`L-�✓ (� : J N/C CONTR L#
.ARCfT/ENGINEER: LIC yOy _� ADDRESS: ❑
CDNT1na/'•:1,. �- - �/I/w����` PHONE: - � QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
W'{} �• L�wl a � BLDG ELECT PLUMB MUCH
•' , 1 PERMIT ISSUANCE 11 El Ip ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
C C Z. I herebyafGrm thm l am licensed under provisionsofChaptm9(commencing with TOB DESCRIPTION
R40O Section]Wm)of Divisor J of IM1e Business and Professions Cade,andmy license is in PANEIe
FmyLFW. full(areaand effect. i
is:,-t fullLicenseaass Lic.p IIP TO 200AMP5 \J W'l•-' l//
m<H Date Contractor 201-1000 AMPS
ZoZ ARCHITECTS DECLARATION
� OVER IOOO AMPS SQ.FT.FLOOR AREA $/SQ,FT.
O Z-O I understand my plans shall be used as public recons.
SIGNS ELECTRICAL
Licensed Professional
X,
X< OWNER"BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyU I hereby,affnnfar I am exempt from the Commences License Taw for the
W 3 a ti
following reason.(Section 7031.5,Business and Professions Code Any city or county TEMP.METER OR POLE MST.
which requires a permit to construct,alter,improve.demolish,or repair any structure
CWQS prior to its issuance.also requires the applicant for such Permit a signed statement POWER DEVICES
fye�<O Than he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapin
k�STORIMn 9(commencing with Section 7000),(Divisl,n SofNe Basian.and ProfessionsCode) SWIMMING POOL ELEor that he is exempt therefrom and the basis for te aIle ed exem t An g pion. y violation ofSection 7031.5 by any applicant for a permit subjects the applicant m a civil penally of OUTLETS-SWITCHES-FIXTURES
ut mare than five hundred dollars(f5mm). NEWRESIDENTIALELECTR 5❑ Lus,wnemftheprnpeny.ormyempinyecswithwagesxstheirsolecompmsafion, 0'i5 e-2 willduthe work,and the structure isnotintendedoro(find for sale(Sce.'l014,Business
and Professions Colic:'fue Commonrs License Law does not apply to an owner of
pmpeny whobuildsor improves thereon,and wh,doe-ach work himselforthroughhis
employees.providedthm such improvementearenm imendedoroffered formle.If.however.the building orimprovcment is sold within one year ofcompletion,theowner- TOTAL:
builder will have the burdrn of proving that he did not build or improve far purpose ofsale.).
❑ I,asowner ofnbe property,am exclusively contracting with licensed contractors no QTY' PLUMBING PERMIT Z- ,v
,n tum the n Sec.7044,Basin,.and Professions Code:)The Communities
Prose l
Lkcnscl.awd«snot apply tom withavnfpropcny who
nsedpsorimproves thereon,and PERMIT ISSUANCE
Live a ...forsuch projects witha<onnacnorts)IicensM pursuant nn the Contractors
Liaensc Law. ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE O SIDE FEES
SANITARY Y_N
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT
WOR KMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ Iherebyuffrmnhet l have a certificate m.1ocasentro self-inaim,or a certificate of FIXTURES-PGR TRAP RECEIPT'#
Workers'Compensation Insurance oro ocif l cm ytherndOSx.3&)m Lnb C.)which PARK FEE Y_=FTl.E
N_
cover,.11 employee's and 6 GAS-EA.SYSTEM-I INC. 0UTLETS RECEIPT Policy#- SION FEES
Company GAS-EA.SYSTEM-OVF,R 4(EA)
❑ CcnifN copy is hereby tomo ed.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP COMPENSATION INSURANCE A(This miction need not be c,mpldcd if the permit is(Drone hundred dollars(5100) SEWER-SANITARY-STORM F.A.2mOFi'. .orlas)I certify that in the pMonnmueofthe workfor which this permit is issued,l shall WATER HEATER W/VENVELECTRnot employ any person in my manner so av to become subject to Ne Workers AID
z Compenmtinalaws,f California. Date WATER SYSTHWIREATING
APPliecon Date RweiplN
z 0 NOTICE TO APPLICANT;If.after making this Camfictte of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT.
F4 became subject to the Worker's Compensationmm pvisioof the Labor Code,you must TOTAL:
forthwith comply with such provisions or this penldt shall be deemil revoked.
(Y � a BUILDING FEE
a z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thm there is a construction lending agency for the pertmmance of ,tsA
U O -he work for which this permit is issued(Sec.3092 Civ.CJ TOTAL: �_yy ELECTRIC FEE
Lender's Name
IL F Icndc/s Address QTY. MECIIANICALPERMIT FEE PLUMBING FEE OQ
U I comity that I have read this application and state that the above information is
arrriccn. lagrcc to comply with all city wdcountyominancce and stat ws rcHfingto PERMIT ISSUANCE MECHANICAL FEE
_ buildingconsnuctum.mulhemb"domiaene - native o thi. emernpnnthe
U z ulnvomcmimadpmpertyf inspemi,npurpous. ALTERORADDTOMECH. CONSTRUCTIONTAX
(We)ague to save ' comfy and k«p h ny of Cupertino against
liralities.judg nts, ani h' h y wayaccrueagainnsaid City AIR HANDLING UNIT(TO 10,(100 CFM)
rnnsequco f gran'
Is AIR HANDLING UNIT(OVER 1m,d00 CFM)
Sign of Applicm not or Dale EXHAUST HOpU(W/DUCT) I"a_- -�
PAID T=C�I2�C S=C
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,020 BTU) Date Receipt p
Will the applicant or future building occupant store or handle hazardous material �yf
as defined by the Cupertino Municipal Cork,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL: V y-
Code,Section 25532(a)7
❑Yes EI No VENTILATION FAN(SINGLE RESID)
Will the acraniumor(more building by themuse equipment ordevicesanage emit
BOILER-COMP(3HP OR 10,(00 BTU) ISSUANCE DATE
Dixuric" air ronnamiwnts as dcOnml by the Bay Area Air Quality Management BOILER-COMP OVER 110.000 BTU
Dist c� P A I D
El Yes ❑No NEW RESIDENTIAL MECI I. SQ.Ff.
I have read the ha ydous materials requirements under Chapter 6.95 of the FEB 1
California Ilenhh&Safety Calc.Sections 25505,2553)and 25534. I undersand that 41995
L7
the huilding does not curzcnmy
have
a mnanl,Thal n is my respmsibility n,notify the
Ocupant of the requir meats which must be met prior no issuance of a Cenifcme of
ccupancy. CII f laU(-L'f1I IfV(J
Owner or awhorizcd agent Date I
TOTAL: ISSUED BY: ✓L{..
OFFICE