27664 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHULL IN -hLh. IRICAL PERMIT NO.
APPLICATION/PERMIT BUD,PLUMBING-MECIIANICAL 27664
BUILDING DIVISION DINOMIJECTIDEN'I IFICATION
BUILDING ADDRESS: SANITARY NO. I APPLICATION NUBM I I-I'AL DAI 17.
/0470 UNIT# LOT l'i rlo-jast
OWNERS It PHONE: CONTRACTOR'5 NAME: LIC NO:
mQ. --a. riou r>E/ZW4i- -rNE tro.a.H6AeT Paw N6 CO_ N/C CONTROL Of
RCIII'1'ECT/I7NGINEER: LIC NO ADDRESS: ❑
7550 Locr{F OQQ cT, CvpElCr Nn
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INEO
BLDG ELECT PI.UMBMECH
PERMIT ISSUANCE 1:1 El Nal,
/ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRII'1'ION
09z I hereby affirm Nat Ch
I am licensed under provisionsofapter 9(commencing with ^
WOO Section)000)of Division J of the Businev and Professions Code,and my lianae is in PANELS
[—tus�.� full force and efftt1.
6FZu! License Class L 3G• Lic.p G24342r UP T0200AMP5
NayDute Contracnn 2111-1019 AMPS SQ.11f.FLOOR AREA $/SQ.FT.
Hy% ARC]I ITECTS DECLARATION OVER]"AMPS
O<—O
c'O0 I undersmnd my plans xhall be used u public records.
FyFLL] SIGNS ELECTRICAL
6Y�j Licensedl4ofcssinnal
ayv�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W0, 1 nhemb,g meson,
ration that I on cncmpt from Nc Gonias Cx e:Any Law far he
W 30 which following t res 0 pe(Sectionur cm LS,Business end Professions h.an Any city or roomy TGMP.METER OR POLE INST.
1_ O¢ which rt4uims a pertnit m arnswd,ager,improve,demolish,m repdr any nmcwm '
to its issuance,also the applicant for such permit file a signed statement POWER DEVICES
prior requires pp pe gal
C Q O Out he is licensed pursuant to the provision of the Conuader'e License Law..Caner
yoy. 9 SWIMMING POOL ELECTRIC VALUATION
44.. (rommcncing w'nh Section OfgtOl of Divisiun3of Ne Business and Professions Cods.)
=y
or that he is exempt therefrom and the basis for the alleged exemption.Anyviolationof ,
}F%Q Section,7031.5 by any applicant for a permit subjects the applicant to a civil penalty of (lU'ILfSTS-SWII'CI1E5-FIXTURLS
m than five hundred .
d drD ($500). NEW RESIDENTIAL ELECfIt S .FT.
KCFF S nC1I,more as owawnfdm pmpcny.or my employees with wages as Neirsole compensational, Q STORIES TYPE CONSTRUCTION
i3— will do the work.and the svucmm is not intended or offered for sale(Sec.7W4,Business ¶
and Proresxions Code:The Contractorm owners License Law does not apply an owner of A
^, 1
-� propenywhobuilda erimprwc.v Ncrcon.undwho dtwesuch—olthimxclfonhroughhi., OOC', R UP RES.UNIIg
n employees,provided that such improvements we not intended nrofremd for sale.If, _ tit,
1
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). •� t
❑ I,m owner of the progeny,amexclusively contracting with licensed contumotmo QTY. PLUMBING PERMIT FEE \ f1 (FLOOD Zp`NE APN
conuuct the project(Sec.7(94,Basion and Professions Code:)The Contractor's t S " \\E J1
License Law doe%nor apply to an owner of property who builds or improves thereon,and I'ERMI'1'ISSUANCIi
who contracts for such projects with a coneractons)licensed pursuant o the Contractor's AL'11iR-DRAIN&VENT-WATER License law. (EA) ( - 1r FEE SUMMARY
❑ 1 am cncmpt under Sec. ,B&P C for Nis mason BACK FLOW PROTECT.DEVICE } OUTSIDE FEES
l SANITARY Y N
Owner Dale RECEIPTa
DRAINS-FLOOR,ROOF.AREA,CONE).
WORKMAN COMPENSATIONUECLARATION SCHOOL TAX Y N
1 hereby❑ em'Compenrmin Il have eorace"eof cnnsealwenif(inxum,or aaninc le ofwhich FIXTURES-PER TRAP RECIiIF'I'p
Workem'Compeims's de,,hii, .i,. ified copy NerroflSee.3go0.isb CJ which PARK FEE Y N
rs all employee's under this permit. GAS-EA.SYS'IEM-I INC.40UT1, 'S ft1:MSI a
Policy a BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ccnificdao,,,hcmhyfuonw,d.
❑ CenilivJ copy is fled with the coy inspection division. GRFASEANDUSTRL WASTE IWHI EPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Riv section need not be completed ifthe permit is forms hundred dollars 5100) SEWER-SANITARY-STORM EA.200 ENERGY FEE
ter.)
lemony that etwo perfony man fNe work torecom subject
alssa[Qlkers W F.R W/VF,NT/EI-F,CfR
not employ any person in any m at m become subjwt m Ne Workers' PAID
Compensation laws of Califumia. Dme so WA RSYS /TREATING Dam Receipt
Q z Applicant
z NOTICE 10 APPLICANT:IL after makingthie Certificate of Exemption,you should RISIDENTIAL PLMB. SQ.FT. TOTAL:
F .�. hccomc,anhjal tnthe Worker's Compensation provisions of the Lehor Code,you mull
forthwith comply with such provisions m his permit shell be deeooilm,oked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7- Z I hereby affirm that there is a construction lending agency for the performance of T ELECTRIC ItiE
U O the work for which this permit i%issued(Sec.3197.Civ.C.)
Lender's N PLUMBING IPER,Lender's Address QTY. MECHANICAL PERMIT FEE
0 U 1 ccnify Nm I have mad this application and stem thatNa above information is - MECHANICAL FEE
terror.Iagmemcomply with all city and county ordinance and natelawx rtletingte PERMIT ISSUANCE
f•-' V) buildingconstruction.and hereby authodm representativesofthis city to enter upon the CONSTRUCTIONTAX
Uabove-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(We)ngmr m save,indemnify end keep mo des,the City of Cupcelno ugalnn
liabilitiw,judgmems,costa and expenses which may in any waywrimeagamisidd City ATR HANDLING UNIT(TO 10,000 CFM)
nu4u<nce of the granting or Nia peon'
`�#"� I AIR HANDLING UNIT(OVER 10,00(1 CFM)
Signature of Applicant/Contractor -�^ ate EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HPA'FIND UNIT(TO 11X1,09 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle locumous material HEATING UNIT(OVER 100,000 BTU) TOT L.
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
Code,Section 25532(e)? VUNTILATION FAN(SINGLE RESID)
❑Ycs ❑No
ISSUANCE DATE;
�
Willthe applicant or future buddingoccupanl meequipment ordevices which emit BOILER-COMP QHP OR 100,M)BTU) � ' D hu=s air contaminant as defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER 100.000 BTU)
Distrio?
111 (�
Yes ' ❑No NEW RESIDFNDAL MECH. SQ.FT. DEC ` f 1s79L}
1 he read the ha'rnrdena materials retporcmcrns under Chapter 6.95 of the
Califomia lhealth&Safety Codc.Sedions 25505.25533 and 25534. 1 undemund that CITY
Brim building does not currently have a union.that it is my resgmsibiliy,to notify the - UI-- (;VIr�G'lrint/4
cupam of the requirement which must be mm prior to issuance of a Cenificau of
(kcupuncy.
Owner or xwhurizcd egem Dam 'f0'1'AL: ISSUED BY:
OFFICE