27987 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBmED3I`rG-REECTercX PCRMrr NO. ^
g4VILDING DIVISION a APPLICATION/PERMIT PLUMBING-MECHANICAL 27 y87
BUILDING PROJECT IDENTIFICATION
BUILDINGAVRPSj.) C SANITARY NO. APPI.ICA'r[ON
SUBMIT]At.DATE
L ` �� LOT#
PHONE: CON'RACTOR'S LIC NO:
D�'a. W _ WC CONTROL#
RCfll' /ENGINGER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E4ECT PLUMB Mf❑CII
PERMIT ISSUANCE Off•/`
LICENSED CONTRACTOR'S DECLARA]'ION APPLIANCES-RESIDENTIAL ^ Y+.��JJOB`DESCR_ IE110N
owz Ihereby affirmthm l amlicenaed underpmvisions of Chapar9(commencingwith 4 HT1 rYJ►\�' PUV
f•JOO Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS «' 111 kk, ww-aa,
,w— fon forte and effect.
aZw Licence Class Lic.N UPT02WAMPS
y=y Date Canute, 201-IOWAMPS
ZFO z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA SISQ.I.T.
O Z—G I understand my plans shall be used as public records.
F=Fw SIGNS ELECfItICAL
QY2j Licensed Professional
�yd'Q OWNER-BUILDER DECLARATION SPECIAL CIACUfDMISC.
XOaO 1 hereby offimt Nat 1 an exempt from the Cantsacmr's License law far the
W�O`Fej following mason.(Section]031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
which mutinies.permit m commua,alter,improve,demolish,m repair any structure
5�o,}� poor o its issuance,also requires the applicant mrsuch permit to file a signed statementPOWER DEVICES
C Q that he is licensed pursuant to the provisions of the Contractors License Law(Chapter diVALUATION o 9(comnarting with Section 7001 Division 3ofthe Business and Profession Cade) SWIMMING POOL ELECTRIC
Wufthnfic isexcropuherefmmund the basis furtheellepolinmmption.Any violation of !l isw4r/e
FZQ Seaion]B3L5 by any npplicnnl fora permit subjens the applicannoacistpersta of OIITLEI'S-SWRCHES-FlXTURES
W-oFlol more than rive hundred dollars(S530). NEW RESIDENTIAL ELECIR SQ.FT.
❑ Lnownerofthe property,ormyemployeeswith wages as theirsolecampemadon, STORIES 'TYPE CONSTRUCTION
a3a-e willdo the work,and the structure is not imendedoroffered for sale(Sec. Business
and Professions Code:T1m Convacmrs License Law does not apply to an owner of
property who builds or improves lhemm,and whodoes such work himselforthroughhis
employees,providedthmsuchimpr..vcments mount imendedoroffered forsale.If. OCC,GROUP RES.UNI'T'S
however,the building or improvement is sold within one yearofcompletion,theowner- T i`—
builder will have the burden of proving that he did not build or improve for purpose of
sole')' PLUMBING PERMIT FEF:
❑ Las owner oflhc prop dy,ant exclusively conducting with licensed contractors to FLOOD ZONE AVN
QTY-
construct the project(Sec.7044,Badness and Professions Code.) He Gmlmemrs
License Law docs not apply to an ownerofproperty wholumidsorimprovesthereon,and PERMIT ISSUANCE
whoc,,at.x¢fn...ch projects with.antmenors)licensed parts...Imthc Contracmrs
License Law. pLTGR-DRAIN&VENT-WATER(FA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for This reason HACK PLOW PROTECT.DEVICE OUTSIDE FIATS
SANITARY Y 14
Afti Owner Dale DRAINS-Fl,OOR,ROOF,AREA,COND. RECCIF1'A
TI �.
WORKMAN COMPENSATION DECIARA]'ION SCHOOLTAX Y N_
❑ �hcreuy off dm thatlhuveacenincete of rnnscm mrd Ginsurc,sera nenilicme of RECEIPT
FIXTURES TRAP
korkets Compensation Insurance or a certified copy lhemofl5a.3g(NI,Lub CJ which PARK FEE YN
covers se _
ll employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RI-CLI #
y# BUILDING DMS NFEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenif,d copy is hereby furnished.
❑ Cenlficd ropy is filed with Ne city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
C11THFICAT11 OF INN FROM WORKERS' GREASE TRAP SOILS PEG
COMPENSATION INSURANCE
This section need not becmnpleted ifthepmnit is for one hundred dollars($1 00) SEWF,R-SANITARY-STORM EA.20017. ENERGY FEE
or In..)
I cenifythat in the famorromee of the work far which this percent is issued.)shall WATER HEATER WNENT/ELECTR
not employ any petam in any manna n to become subject ro the Workers PAID
Ic 11
Compensnionlawamf California. Dan m WATER SYSTEMfrREATING Data ResciplN
O z Applicant
zO NOTICETOAPPLICANT:IL after making this Campeau,of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
TCI) become subject m the Workera Compenmuon provisions of the labor Code.you must
� > forthwith comply withauch provisions or this permit dust be decreed revoked. BUILDING IEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
If
CL I hereby affirm that there is a construction lending agency for the performance of
U z the work far which this permit is issued(Sec.3119].Civ.CJ T ELECTRIC FEE
U O Leader's Name
�' F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBINGFEE
U 1 certify that I have read this application and state that the above information is MECHANICAL FEE
14 correct.l agree m comply with all city attd county ordinances and state laws relating to PERMIT ISSUANCE
(— buildingmnstmaion.and hereby nutho' nmdvea of this city mercer upon the CONSTRUCTION AN
(� Z above-mentioned property for ins non pa ALTER OR ADD TO MECH.
1 N I agree to sav Trash y and keep h teras Ne City of Cupertino against
to ib s andcx useswhi<h yinanyway emeagautams City AIR HANDLING UNIT(TO MOXI CFM)
in<n ry sf th r ting of 's permit
AIR HANDLING UNIT(OVER 10,1%10 CFM)
Signaw caMConmaaor Dale EXHAUST HOOD(W/DUCD
PAID
IIAZARUOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dale Receipt#
Will the applicant or future building meupunt node or handle ha)ardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Ilealth send Safety TOTAL:
Code,Section 25532(x)] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100.0010 BTU) ISS1iA DATE
Will the applicamor fuwrtbuildmi,oceupanl useequipmenmrdeOtmwbicb emit !" s
Nous air comaminanls:n defined by the Bay Arc.Air Quality Management BOILER.COMP FILM BTU)
Net, k
❑Yes ❑Nn NEW RESIDENTIAL MECII. SQ.FT. APR 2s1n(]
I nava mad the hazardous materials rcyJrctnents under Chapter 6.95 of oto Ory 5
Califamialleullh&Sura,Code,Seclitns29505,25533tnt125534. Iunderstmi that UF LUNL
if the building docs not currently have a wnmt that it ixmy responsib'dily to notify the
CH lNU
ccupam of the reywmmems which must M atm prior m Issuance of a Certificate of
Occupancy.
Owner or aulhorimd agent Date TOTAL: ISSUED BY:
OFFICE
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