27303 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .nlfac:-RLt:LTKIC PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMItING-MF.CIIANICAL O
BUILDING PROJP.0 1'IDEN'1'IF'ICA'1'ION
BIDING ADDRESS: C�- UNIT# LOT SANITARYNO. APPLICATIONSUBMIITALDATE
53 1 V v ?tel S
O SNA li: H C N'RACL'OR'S NAME: LIC ND: NIC CONTROL#
•ARCHITHCT/ENGINEER: LIC NO: IBES\ � , 1 ,.�� ^ ❑
cONTAn': pxaNC: QTY. 1 ElL_EC'TRIC PERMIT \V FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB 2drctL
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION - APPLIANCES-RESIDENTIAL JOB DESCRIPTION
q0z Thereby off Di Nutl 3 office
sed Business and rofesions Coer and my ficane is in �(
WOO Section l0(g)1 of Uivision3nf Ne Business end Professions Code.and myliunse is in pANBIS
FMy-'V6mllforce and cf t.
FZW Litt CIn
Lia# UP T02fq AMPS
N?y Dine
crooned, nJa, 201.1000 AMPS
ZOyL` .ARCHITECTS DECLARATION OVCR 1000 AMPS gQ.Fr.FLOOR AREA $/SQ.Pr,
O Z'-'O I understand my plans shall be used as public n,coNs.
r 4 t od SIGNS ELECTRICAL
Licensed Professional
W OWNER-BUILDER DECLARATION SPECIALCLRCUIT/MISC.
xoi I hereby mffnn that I um exempt from the C.mmcmr's License Law for the
W�'�m falrovng reason.(Seripn 7031.5,Business end Professions Code:Any city.,county TEMP.METER OR POLE MST.
which requires a permit e,cnnstrun,alter,improve,demolish,or repair any mmemr,
�apriormitsissuance,alsorequiresOreapplicantforsuchPermittorileasignedstatement POWER DEVICES
W
00 that he is licensed larsuanno the provisions of Ne Condom,.License law(Chapter
4pF� 9(commencing with Section 700E of Division 3 ofthe Business and Profession Code) SWIMMING POOL ELECTRIC VALUATION
W--y or that he is exempt Nerefromand the basis for therdleged ascription.Any violmionof OUTLETS-SWITGHE$-FI%NRPS
Fq- >• Sermon0031.5 bymyapplicantt
t fora psndimbicets Neappliceno.civil penalty of
2 6 not more than five hmulreml dollars($500).
WY] ❑ I,mownemf Nepropeny,ormyemployeeswithwagesastheirsole comprnsadon. NEW RTSIDENTIALELECIR _SQ.Ff. STORIES 1'YPECONSTRUCI'ION
willd.the work,and timtncome is no,maeudedornfferm for mli,(Sec.0044,Business
and professions Cole:'rhe Contractor's License Law does not apply to an owner of
pmpeny who builds or improves thereon,and who does such work himself or through his
wnemployees,pmvidedthatsnchimpmvementsamnotintendedoroffemdforsale.TL OCC. OUP Rl'S.UNITS
however,the buildingor improvement is sold within oneycarof completion.the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L asnwnerofthe progeny,am exclusively connecting with licensed contractors to QTY. PLUMBING PERMIT FEiG FOOD ZONE. APN
construct the project(Sec.7844,Business and Professions Code:)The Con.enm's
Lcense Lawdoesnmapply tom.,merofpnclim,who builds.,improves therttm,and PERMIT ISSUANCE
who coontem forsuch projects with.conlracmr(s)licensed pmarcenuo the C.mmctor'e ALTER EA FEE SUMMARY
License Law. ( 1
❑ I am exempt under Sei. ,B ffi P C for Nis reason BACK MOW PROTECT.DEVICE OUTSIDE MRS
SANITARY YN
Owner Data RECEIPT p
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA COND. SCHOOL.TAX Y N
xr1 hereby affirm that I have a eenificate of consent to self.insum,or a certificate of RECEIPT#
FIXTURES'-PCR'fRAP
Wnrket%Cnmpengsem�ioynnldnCsurance tormoBc_eniliedcopy there.f(Sec.3g00,LaM1CJ which PARK FEE Y N
coversPolicy y Illktbs�`V� RECP.IP#
GAS-P.A.SYSTEM-I INC.40UTLF,TS BUILDING DIVISION FEES
Company GAS-EA.SYSTHM-OVER 4(RA) PLANCHECK FEii
❑ Cenifictl copy is hereby famished,
Certified ropy is fled with the city inspection division. GRFASFWNDUSTRL WASTE.:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOBS FEF.
COMPENSATION INSURANCE
Thissection need not be completed ifthe pemmil is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE '
or IcssJ
I arify,hru in he performance of the work for which this permit is issued,l shall WATER BEATER W/VENT/ELECfR
not employ any person in my manner an as to Ixxoma subject to the Workers' PAID
Compensation Luwsef Califomia. Dole WATER SYSTEM/rRRA11NG Date Receipt if
O z Applleam
z NOTICE TO APPLICANT:LLafer making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
e-I U) become subjectto The Workne,Congedminn provisions of the Labor Cods,you most
Fri > forthwith comply with such provisions or this permit shell be deemed revoked. BUILDING ItE
4 Q - CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z L hereby affirm Nut there is a construction Imding agency for the performmce of - TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.C.)
lander'.Name F PLUMBING LEG Lenders Address QTY. MF.CI IANICAL PERMIT FET.
U I crash,Nat 1 have read this application and state thin the above information is
�" a corms.lagreemcomply wish ell city and county ordinmcee antlstete laws relating to PERMIT ISSUANCE. M MECHANICAL OR.building construction,and hereby authorize representatives ofthis city turner upon the30QW CONSTRUCTION'fAX
U 2 move mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agrcc to save,indemnify and keep harmless the City of Caperton against
liabilities,judgments,crisis mut calmest which may in my way uccme against said City AIR BANDLLNG UNIT(TO 10.000 CFM)
nigcnn seat nee of the graining of Nis ;tri. q�a�lqt
ALR HANDLING UNIT(OVER 10,IX0 CFM)
olApplicnVContrum�r
CXFIAUST IIDOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATPNGUNIT('1'0100,00BTU) Data Receipt
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT OVER I(gP,(Xq BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hath and Safety
Code,Section 21532m)?Ya 1:1 No VEND ILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) �SSAk jCi��DATE
Will the upplicam.rfmurt bvildingacupum use equipmemardeviaswhichemit -
hazardous air contaminants as deOncJ by the Boy Area Air Quality Management BOILER 100,000 BTU '
District, OCT 21996
EI Ye., ❑No NEW RGSIDENTIAI.MECH. SQ.PI'.
1 have read the hazardous materials requiremcros under Chapter 6.95 of the
I /s1IY Ur NV
CalifnrniallcnlN&SafetyCaie,Seniors 25505,25533 and 25514. umderstandthat CLUr m
if the building does not currently have a tenet,that it is my n,wnsibility to notify the
occupant of the requirtmems which must he met prior m issmmce of o Cmnifcete of
Occupancy. -
0wneror amhnrizcd agent - Date TOTAL: 3.0o ISSUED BY:
OFFICE