27305 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINODING-I'LRCTIR . PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICA'T'ION
BUILDING ADDRESS: ` 1 SANITARY NO. APPLICATION SUBMITTAL DATE
Y/' pl, UNIT LOTH y 1
NCRSCN_A'ME: \ HO _—' O C C[OR'S NA i. CNO N/C CIOVJNTROLN
an
ARCHITECT/ENGINEER: LIC NO: D S: r ' �Ls!� El PHONE: �
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ECP PLUMB -MECH
PERMIT ISSUANCE
11 %fff
LICENSED CONTRACTOR'S ionsof ATION APPLIANCBS-RQSIDENTIAL �.. rpl�AnN
❑xZ Ihereby 7")oaffirm ision 3 ofth Buiunder
and isimsions Cod. nd my It=g with
{+100 Sttsion 7")of Division3 of the Business and Professions Cade,mW mylicenu is in PANELS
fFf�� full force end •1n ,
<Z Lima = _ —�/ Lic.N� UP T0200AMP5
ti6y Dme Conuacmr n7 201-Iqp AMPS
Z FOy ZJ ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FI'.
O Z—G I understood my plans shall be used as public excoma.
F4ro W SIGNS ELECTRICAL
ssJ Licensed Professional
�J OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
sd(Oa V I hereby affirm that IJ_ 03-00
not exempt form the Contncmis License Law for the
W 3 W ti following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Eewhich requires a Permit.exam n.s,eller,improve,demolish,or repel.any...tort
se}� prim to its issuance,also rectums the applicant for such permiuo file a signed statement POWER DEVICES
�0K that he is licensed p....at.the prcwchnsoflm Commuter's License Law(Chapter SWIMMING POOL ELECTRIC
aaQ 9(commencing with Section 70110)ofthsisioa 3 of Ne Basin'.and Professions Code) VALUATION
or or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
54G Section 7031.5 by any applicant for a permit subjmus the applicant o a civil penally of
O t more Then five hundred dollen(5500). NEW RESIDENTIAL ELECIR —SQ FT.
1M,,50 n❑ I,asownerofthepropeny,ormyemploymswithwagantheirsolecompensmion, Q STORIES TYPECONSTRUCI'ION
p^, will do the work,and the s.cwm isnot intended oroffered forade(See.7W,Business
and Professions Cade:The Comaratme,License Law does nm apply to not owner of
property whobuilds erimproves thereontand who dcessuch work himselforthmughhie
ownernployms,provided that such improvementsannot intended oroffcred(male.If, OCC.GROUP RPS. ITS
however,the buildingor improvement is old within one ye.rofcompletion,dreawnes- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mawnma
erofthe Property,aclusively contracting with licensed.. .. QTY, PLUMBING PERMIT FEE OOD ZONE APN
cnns.ct the project(Sec.7044,Business and Professions Cada:)The Contractor's pERMI'1'ISSUANCE
License Lawdonnalapplytoanownerofpma nywhobuiIdswimpmvmthmean,and
whoconlocra farsuch projttls with a coulractons)licensed punuanttuthe Contractor's se Law.
License
ALTER-DRAIN&VENT-WATER(12A) FEE SUMMARY
❑ l stn exempt under Sec. ,B&P C for this reawn BACK FLOW PROTECT.DEVICE OUTSIDEFEES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPTN
c _ WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
Iherebyofforathatlhaveettnificate of consent to self-inmrt,oreatrifinm of FIXTURES-PER TRAP RECEIPTp
44�ikerx'Compenesaetyio�anN dInrssu4rIa��ncNet�or�e�ccnified copy thereof(Sec.3gW,l.ab CJ which PARK FEE Y N
coversall /IUR7. RECEIPTN
Policy p�Il.f i•L7 r GAS-EA.SYSTEM-1 INC.d OUTLETS BUILDING DIVISION FEES
Company kT'u �S GAS-EA.SYSTEM-OVER 4 EA) PLANCHECK FEE
�.❑ Certified copy is hereby furnished.
yp Cenificl copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PER
COMPENSATION INSURANCE
(This sectiatmedim be completed ifthe permit is forme hundred dollmc(f 100) SEWER-SANITARY-STORM EA.2001ef. ENERGY FEE
or leu.)
I certify that in the performance of the Work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in my mover w u to becmne subject to f.Workers PAID
Z Compenmum"wcof Ctifarro, Date WATER SYSfEM(MRATING Dam Receipdp
Applicant
O NOTICE TO APPLICANT.If,after making this Cersfiu.of Exemption.yen should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
fn become subject to the Worker's Compenssdm provision of the Labor Cade,you must
a ; forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
LLLVVV::: z1 hereby affirm that there is a construction lending agmcy for the perform.of
the w
O ork for which this Permit is issued(Sec.3097,Co.C.) TOTAL: ELECTRIC FEE
LL1 t-.1 lender's Name
LU•1 Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify Neel 1 have read this application and ata.Nor the above information is
acortex.l agree to comply with all city and county ordinances and slate laws relating toPERMIT ISSUANCE •�^/'++'l MECHANICAL FEE
" to building construction,and hereby auNminreprcsenlatives of Nis city lumbermen the AJC III) CONSTRUCTION TAX
U 7 above-motioned propmy fm inspection purposes. ALMS OR ADD TO MECH.
G (We)agree m save,indemnify and keep harmless the City of Cupertino against
Iiabiloics,judgments,coati nodexpensex which may in my way accrueagaiml said City AIR HANDLING UNIT(TO IO,M)CFM)
I n ca ry tt of th granting of Ni pe it.
Ifty AIR HANDLING UNIT(OVF.R 10.000CFM)
ter of APPlicm/ConBaamm
. EXHAUSTHOOD(W/DUCG
PAID
HAZARDOUS MATERIA SCLOSURHEATING UNIT(TO 100,000 BTU) Date Receipt Is
Will the applicant or future building occupant store or handle hmardam mamriul
as defined by We Cupertino Municipal Code.Chapter 9.12,and the l health and Safety HEATING UNIT(OVER 100,000 BT U) TOTAL:
Code,Section Yes, q7 ❑No
❑ VENTILATION PAN(SING LE RESID)
Ya
Will the buildingmcupmmse equipmrnmr devinswhich emir
BOILER-COMP(31/P OR 100,000 BTU) ISSUANCE DATE
hazardous air contmninmts as defined by the Bay Amo Air Quality Management BOILER-COMP(OVER 10t BTU) /
Dlstrlcl'I ,S
❑Yea, 11 No NEW RESIDENTIAL MECH.—SQ.FT. &g OQ
I have read the hazardous materials requirements under Chapter 6.95 of the /s > ® /♦
California I leahh&Safety Code,Sections 25505,25533 and 25534. I undermmd that
if the building docs not currently have a terror,that it is my responsibility to notify the L''I
cupant of the requirements which must be met prior to iscunme of a Cmifiame of
Occupancy. �1
Owner or autho axed agent Data TOTAL: ISSUED BV:
OFFICE