27717 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . 7rPTIKCTRTCA PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27717
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
AvFUNIT LOT# 01
�/l ur
OWNISR NAME: PHONE: CONTRACTOR'S NAME: LIC NO: !J� 1
r N/C COMROLp
ARC ITECI'/ NGINEEW LIC NO: ADDRESS: ❑
D L
coNTncr: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ -It'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
qtr T, IhereM1yaffitm the lam licensed underprovisions of Chapter9(commencingwith
FJ O C Section 7I1001 of Division 3 of the Business and Professions Code,and my license is in ppNEEq
W IF-. full force and IT t4 �!q
FLw License I's J Lic.N�/•,4FE!� �.A UP T0200 AMPS l
yQy Dum Coneactnr asAWL 201-1000 AMPS
>�yZ ARCIIITECTS DECLARATION # OVER 1000 AMPS
0z_n I understand my plans shall be used am
s public recds. SQ.FT.FLOOR AREA b/SQ.I.T.
QYj lacenxd Professional SIGNS ELECTRICAL
CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUEDNHSC.
Xowu I hereby affirm that I nm exempt from the Contmemes License Lew fm the
f�0n following reason.(Section 1031,5.Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST.
,n which requires a permit in consmuct,alma improve,demolish,or repair any structure
MW}7 prior to its issuance,also requires the applicant for such penntto file signed statement POWER DEVICES
W C G Oz that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
d KCLL 9(commencing with Section700BofDlvi.ion3ofthe Business.nd Professions Code) SWIMMING POOL ELECTRIC VALUATION
WM,n or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
1-Z} Section 2031.5 by any applicant for a permit subjects the applicanuo a civil penalty of OUTLETS-SWITCHES-FIXTURES
E S a0 mm nwre thin five hundred dollars($500).
K F_o ❑ 1,asowncroftheproPcrry,orm to as withwa csastheirsolerom NEW RESIDENTIAL ELECIR _SQ.ET.
Ycmp Y g pensation, STORIES TYPE CONSTRUCTION
W will do thework,and thesurrome isnot intended aI.Ifeled for arle(See 70M10,Business
and Professions Cale:The Commucim s License Law does not apply to an owner of
propcny who builds or improves thereon,and who does such work himself m through his
wnemployees,provided that suchimprovcmentsere not intrndedmofferW forsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearol'completion,theowner-
builder will have the burden of proving that he did not build or improve for pnryou of TOTAL'
sole.).
❑ 1.uownerofthepropeny,amexcrosivelyronmctingwmlianmdcona torso QTY. PLUMBING PERMIT FEE FLOOD-ZONE APryr
construct the Project(Sec.1044,Business and professions Code)'The Contractor'.
Licensclawdmsnorapplymanownerofpma ywhobuildsorlmpmvcsthereon.hand PERMIT ISSUANCE
whocnmrmas for such projects with a conductions)licensed pursuant othe Contractor's
License law. ALTER-DRAIN&VF R(EA) FEESUMMARY
❑ 1 am exempt under Sm. B&P C for this reason tFIKFURES
FLOW PROTECT.DEV IC OUTSIDE FEES
SANITARY YN__
Owner
Date S-FLOOR, A.COND. RECEIPI'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y-N-
o
P/I herebyaffirm that l have.certificate ofermardto xlf-inamt a anificam of -PIiR TRAP 0 RECEIPT'#
Worked Compensation lnsuranecorucenified copy thercof(See.38W.Lab C.)which PARK FEE YN__
mvcrs.11empinye{ �de/th' q�r�yL GAS-EA.SYSTEM.I INC.4 OUTLET RF,CEIPPp
1'ulicyN . saga- OBJ fico��
Company OEC �'� BUILDING DIVISION FEES
❑ Cenified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FF:E
COMPENSATION INSURANCE
(This section need not be completed lithe permit is for one hundreddollma($100) SEWER-SANITARY-STORM EA.200ET. ENERGY FBF,
or I..)
I ccnify that in the performance ofthe work for which this Permit is issued,I sha11 WATER HEATER WNENT/F,LECTR
not employ any person' any manner as m biome subject to the Workers PAID
z Compenaabon Lawsuf Califomma. Date so WAI'ERSYSTENU REATING
Applicant Date Receipt#
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT.
(: V] become subject to the Wmkds Compenxtion provisions,ofthe"hm Cade.you must TOTAL:
fanbwith comply with such provi.vions or this Permit shall be deemed revoked.
CC 7 BUILDING FE[
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm thanhere is.consvuctimm lending agency for the surf ecof
U O the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
O U Unders Address QTY, MECHANICAL PERMIT' FEE PLUMBING FEE
W 1 ccnify that 1 have read this application tend stem thin Ne above information is
0.. correct.I agree to comply with all city and county oNinvnees and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
(� building construction,and hereby authorize repecunistivesofthis city to enter upon the
U 'z a(nve-m raimned property for inspection puryoses. ALTER OR ADD TO MECIi. CONSTRUCTION TAX
(Wo)agree to save,indemnity and keep harmless the City of Cupertino against
llabilitiea,judgmems,collared a....swhichmay in any way we,sx. ars,said City AIR HANDLING UNI'I'(T010,OIX1 CFM)
insegranu of this3eomit.
�/��Q� _ AIR HANDLING UNIT(OVER 10,000 CFM)
Sm , are of Appl man oro ctor-- `/ Date E(HAUSTHOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,pp BTU) Doc Receipt# ('J
Will the applicant m future building occupant more or handle hazardous material
as defitmJ by the Cupertino Municipal Cade,Chapter 9.L2.and the Health and Safety HEATING UNIT(OVER IM."BTI!) 'TOTAL:
Code.Section 25532(x)?
El Yes 1:1 No VENTILATION PAN(SING LERFSID)
Will thea Iicantorfuturebuildin oecu ant us, BOILER-COME QHP OR 100,000 BTU , ISSUANCE DATE
PP g p equipment unlit Mainachnead 1
DwriO us air cnmaminanfs ns defined by the Bay Ares,Air Quality Management BOILER- ( -
Diavin? COMP OVER IW,IXIO BTU) Q
L
Ycs ❑No NEW RESIDEM'IAL MECH., SQ ET. AUG (y 8 199p
reed the hazardous materials requirements under Chapter fi.95 of the I/ s7(a'!�
a I
g oes hot ety Code,See a o nam.that itis y responsind 255y4. I ondersmnJ that Califg docs not cutren0yhoc a mount,the it is my msponsibiliry tonotify thei /he requirements which must In met prior to ou,noee of a Cenifiwte of
\�/�honsrd agent Dam TOTAL ISSUED BY: V �•/ ♦ f
OFFICE
I