27824 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ITUILHING-BLF.CTRI AL PERMIT NO.
/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION APPLICATION IUILUN:1NUJEcrIDEN1'IFICA'1'ION 27824 7on4
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DA'IE
UNIT LOTH 2
pM4yiR. AME: PITO ACTOR'S NA ' IC NO:
L N/C CON RDLp
•A RCHI'IECI'/FNGINEF.R: LIC NO: DRESS:
/ F1S
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE BUILDING
BLDG PLUMB
MECIL
PERMIT ISSUANCE aa` red(
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
owz Ihereby affirm that l am licensed under provisionsofCTaphar?(commencing with JOB DFSCRIPI'ION
4110LF0.. Senlnu]000)of Divstoolot the Bminesand Profession..Code,county license is in PANELS
FZw hider Clad cffe Lic.X
�� 9/�, U1-IOMAMP5
HQd Dom)/Z 6 Conucmr 2(11-I(Xp AMPS • ,\/��� 11CJV\J
FhZABOUTECFS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
O0L-- l understand my plans shall be used as puhlic records. OVER 1000 AMPS
rat F W ` SIGNS ELECTRICAL
$'�aadd$J iccnxJ ProfessionaF
py'aQ OWNER-BUILD fr.ttC Cmuma ON SPIiC1A1.CIRCUIT'/MISC.
pxa�..OaU I hereby affirm that 1 am exempt fnsm the Contractors License Ww bathe
ta13v-r~i,
F pj0 Q inn]03 o- 1ndioAny city oraunty TEMP.METER OR POLE INST.
whichrectums.pcouiltonamel,auf,improve,demolish,nmpair
any swemm
that he s licensed pursunt to th provisions
rvisiosothe Co pronoun License
Law
a smtemem POWER DEVICES
)yKpp 9(r heislicer,with rsction7hepro Disisn 3 of the Business
License Low(Choors oe) SWI MM I NG POOL ELECT RIC
LWo,' 9(um:mens logpttherefrmandthe Division?e alleged exem and .Any violation
of '� VAaL�UIA,TI,ONS
iW_m Sectioor that n
i31.a bytinyrcWmwdlbe Escbasort subjects
tsthedeaemption.Any viulaYon of - J W
�ZQ Seninn]0?LS by tiny applicumforupermit xubjec¢the applicant toacivil penalty of OUTLEfS-SWIT CHFS-FIXTURES
am,nom than five hundred dollars(5500).
SFO NEW RFSIDENTIALELECIR _SQ.IT. STORIF' TYPECONSTRUCTION
❑ Loaow work.
an The% clumis yemprared offeregeeaatic(Se le compcmation,
will dothawmk.anile Themmianne.,LicaorLawdoes no,apply
m to Business
and Ihofessions CWc:The CnntmctnLs Licenx law dap-nm apply m an owner of
propertywhobuildsor improves thereon,and whodees such work dime.forthrough his
oon cmployce.Toovided that umhiniprovemenis are not imendcdoroffemd forsale.11 OCC GROUT' Bps.UNITS
however.the building car improvement is sold within one yearofcompletion,the owner.
builder will have the harden of proving the he did not build or improve for putpox of
ia1e')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ I,asownerofthepmp ay, mexclusivelycmn aingwithlicenud ntmctento
onswci the project(See.7w4,Bnsiti and professions Coda:)The Commnma
License Lawdoes not apply loan owncrufproperty who builds or improves thereon.and PI?RMI'IISSUANCE
whocantractsforsuchpmjcaswiJaconv tWs)licensedpumuu onContncar's
Licew Law. ALTF,R-DRAIN&VENT-WAT'8R(FA) FIFE SUMMARY
❑nl am exempt under Set. .B&P C for is o:asun OUTSIDE FIT is
BACK FLOW PROTECT.DEVICE;
SANITARY Y N
Owner D:naIt RIiCFIVI'#
DRAINS-FLOOR.ROOK AREA,COND.
L"..' NCO MPENSATION DECLARATION SCHOOL TAX Y N
`❑ I hereby,affirm thutl ave acenificae on
rc.nr a cenifi eof FIXTURIS-PER TRAP BECK X
Workers'Contpcnsalinnln uruneearaccnifcJ copy thcr d(Sec Sg1) 7) M1leh PARK ITE Y N
cover,oil employedn and this permit. 4 GAS-EA.SYSTI' IITLETS RECLI T#
Policy p BUII.DINC DIV ION FEES
Company GAS-EA.SYSTEM- . 4(EA) PLANCHECK FEEIll
❑ Cmifiedeopyishere yfumiahcd.
❑ Cemifial copy is fled hh the city oases mi division, GREASEINDU. ASI' 'I'IiRCI;.IgOR GRADING FEELao) 7
CERIIIICA' iOFP.XEM1'l10 WORKERS' GREASET P SOILS PHE
Cfl PENS NSURANCE
(Thisxctionneed not he pemJiftbe permit is for onehunJred dollars 1$1 00) SE NIT -ST MFA.2WIT. IJJERGY
or less.)
Icenily that in the perfunnanccof dia work for which this permit is luid,(she ll W :R WN T/EL[CI'R
not employ any person in any manner to as to became subject m de Workers PAID
Cnmpetsmion laws of Califnmia. Date WATER SY M/1'REATINC 114c Receipt#
Q z Applicant
zr O NOTICE TO APPLICANT If.after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
l-' .. her no sobjcann the Worker',Compensation provisions of the Labor Code.you must BUILDING FEE
> forthwith comply with such provisions or this permit shall be deemed revoked. Z
W SEISMIC FEE
(� CO NST RUCTION LENDING AGENCY
1 work
for affirm the them is i construction lending agency for de performance of
U z TOTAL: ELF.CfRIC FF
O thewmk for which this pcnnil is issued(Sec.7097,Civ.C.)
lenders Name
u"' F Lender's Address QTY. MECIIANICAL PERMIT FEE PLUMBING( °E
U 1 cenily that 1 hmc rcaJ this application and mum @m 0e above infowation is MF,CIIANIC L FEE Fr
>a W correct.I agree m comply with all city and county ordinances andsme laws relating m PERMIT ISSUANCE.
I--' building conswction,and hetebyautbodu e1)msentalivesoflbincity to enmrupon the CONSTRU ION TAX
V z nhrvmmentioned property for inspection panDoes, AIAERORADD TO MIiCIH.
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against
Iiabilitiea,judgments,command expenses which may in any way accrue against City AIR HANDLING UNIT(TO 10,000 CFM)
7, 71c jaPi�gruming oC th. reit.
r/ 'J O/ �� AIR HANDLING UNIT(OVER 10.000 CFM)
frou re of AppliwnVCwtructor Jou Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING LIST(TO 100.000 BTU) Dae Receipt#
Will thcapplietan or future building recap.,pore or handle hcooticus material HEATING UNIT(OVER 100,00D Bill) TOT
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety pp �T
Code,S,li 25552(.)'? VENTILATION I-AN(SINGLE RFSID) IP A
11 Yes ❑No
ISSUA CE ATE
Will xpplicanlorl'uturu building occupant equipmenmrJeviccs whichemit BOILER-COMP(JIIPOR Ifq.I1fNIBTl1J MAR 22
harm ms air comamimants os defined by the Bay A.Air Quality Management BOILER-COME(OVER 100,001)BTU) 19 E
Disbi",
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. CITY
I have rind the h unlous:nmerlals mym
uireemx under Chapter 6.95 of the OF CUf-EH 11N0
California health&Safety Code,Sections 25505,25577 and 255]4. I understand Nat Or
if the building does not currently have a tenant,that it is my responsibility to notify the
Ooccupant of the requirements which must be met prior to issuance of a Certificate of
ccupancy.
Owner or aulhorineJ agent Date 'I10'1 ISSUED BY:
OFFIC