27238 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINON ILLI G-ELLCIRI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n ff� �O
BUILDING DIVISION BUII.HINT;PROJEC'1'IDEN'TIFICAIHON G r L o
BUILDING ADORES n/ SANITARY NO. APPLICA'DON SUBMITTAL DATE
��P66 UN�IT##1 LOT It
OWNER$NAMlEo. �PIIOca COMfRA�OR'S NAME �.IC�0:�/ N/C CONTROL p ([
• RCHI/TE GINGER: LIC NO: AD R/FSS: C L TI J ❑
�°sv N1cGllni ,rI
CONTACT: PHONE: BUILDING PERMIT INFO
/I QTY. IiLECTRIC PERMIT PIiE
! 1� 7b VO BLDG ELECT PLUME MECH
m � ) / .�hb` �7- PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANC[S-RBSIDF.NTIAL
oma% Ihereby affirm that l am licensed underprovixions of Chapter9(commencingwith JOB UISCRIVI'10/fN4
u]00 Section llNXpof Division Sof the Business and professions Code,a�ndd my license isin PANELS r'(MO�� �— ter 4f
�Ut, full force wd effect. /L 9 wq // 5 r"f-'d
=5 t License Class Liv.# .l UPT0200AMPS
N wrsi Doc Conuanm 201-ugq AMPS SQ.Fr.FLOOR ARBA $/SQ.M.
%Oy= RCUITECPS DECLARATION OVER IOW AMPS
I understand my plans shall be used a public records.
SIGNS ELECTRICAL
Q Licensed Pocipaxonal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOiO I hereby affirm that 1 am exempt farm the Communities License Law for the
W3 u.' loll—loveaon. Section 91131.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
p.u.CJ which"aims a permit to construct.alter,improve,demolish,or repair any stmeture
}� prior w its issuance,also requires the applicant fmsuch Permit o file asignW statement POWER DEVICES s
f4�Q that he is licensed pursuain to the provisions of the Cmilim rs License Law(Chapter aaVALUATION o� m
9(comencing with Seeman 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC }e h
w=on or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
L Z_QSection 7031.5 by any appficam fm mit a perobjects the applicant m a civil penalty of
CFzz nut more than five hundred dollars($5110).
S ❑ Lasnwnemfthc n Im ttswiNwa esauM1cirsulccom tion, NEW RESIDENTIAL ELECIR STORIES 'TYPE CONS'IRUCI[ON
o props y.ormyemp Y B pcnsa
a3_° will do lesions and the he Contractor's
License
La dyes of apply 7o14.Business
and Professions w1 ons ld,o The Ce.,Irk is License Law such
not apply ro an owner of
propcny wlmobuilJsorimpmvea thereon,and whndoessuch wrrkhimsdf onhnmgh hf. Na
IL
employtts.provided that ochimprovements are notinlended rroffcetl(oracle. OCC GROUP RES.UNH S
however,the boldingor improvement is sold withinon,yearofcomplction,theowner-
builder will have the burden of proving that he did not build or Improve for purpose Of
sale')' QTY. PLUMBING P\- IT FEE FLOOD ZONE MIN
❑ E.asownerofthe Mee ny.amexdusivelyconv tingwiWlicenud nt ;oc m
snsn ict the project(Sec.7044,Business and Professions Code:)The Contractors
Liceme Lawdoes not apply us an nwnerrfproperty who builds or improvesthercon,and P17RMIT ISSUANCE
who contras¢for such pmjms with n cono-actor(s)licamttd pursuant to the Conaector's
License Law. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 nm exempt under Sec. .B&P C for thin reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Doc DRAINS-MOOR.ROOF,AREA.COND. RECEUTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IM1creby allinn Natlhavicecenifenme rf cunsennn sdf-insum,nracenilicme of FIXTURES-PERI'RAP RECEIVE'#
WmIsers'Compcnsmimn lnsumnceorattniGcdcopy thereof(Sex.3800.Lud CJ which I PARK FRE Y N
covers all employed under Nis pcmait GAS-G.SYSTEM-1 INC.4 OUTLETS RECEIPT x
y# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(G) PLANCIIECK FEE
❑ Certified copy is hereby fumishsd.
❑ Ccnufed copy is filed with he city inspection division. GREASE/NDUSTRL WASTE INTERCEPTOR GRADING FEE
CURTIFICA'1'E OF EXEMPTION FROM WORKERS' GRFASETRAPN2NIFq.
SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for hundred dollars SIM) SEWER.SANITARY-STORM GENERGY IEE
or less.)
I certify that in the performance orthe work for which this permit is hated.I shall WATER HEATER W/VENT/ELEM
m employ any person in any manner so as W become subject to Ne Workers' PAID
Compennmmc Laws of C.Efi ria. Dame WATER SYSTEM/rREATINGDate Receipt#
zz Applicant
O NOTICE TO APPLICANT:If.after making this Cadficme of Exemption,you should NEW RESIDENTIAL PLM. TOTAL:
t•. co hccnnmsubNctiothe Worker'sCarl.atkin prnvs'rns of the LaMn Codc,you must BUILDING FEE
1� forthwith comply with such provisions or this Permitshall be deemed revoked aB0
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE #SD
Z Ihereby affirm but there is a construction lending agency for the performance of TOl'AL: ELECTRIC FEE O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEEu" F Leaders Address QTY. MECHANICAL PERMIT FEE
U 1 certify that 1 have read this application and stem that the afore information is MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and state laws reading to PERMIT ISSUANCE
F-' buildiagctmnruction,and hereby authorise representatives fibis city roamer upon the CONSTRUCTION TAX
U z abuve-memioncd property fit inspection ForPnos. ALTER OR ADD TO MF,CII.
(We)agree to save,indemnify and keep harmless Ne City of Cupcniao against
liabilities.judgmenre,costs and expanses which may many way scan,against said City AIR HANDLING UNIT(TO 10.000 CFM)
in vuequence of the grami ng of thus
AIR HANDLING UNIT(OVER 10,000 CEM)
Signature of ApplicanUCommtor Date EXHAUST HOOD(WNUC ) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1100,010D BTU) Date Receipt#
Will the applicant or future building Occupant same or handle baysdous materiel HEATING UNIT(OVER 100,1100 BTU) TOTAL: 6 f m S-0
as defined by the Cupertino Municipal Code,Chariot,9.12,and the health and Safety
Code.Section 255I2pd? VENTIG'1'ION FAN(SINGLE RFSID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,1100 BNI ISSUANCE DATE
Will the appllcanmrfumrebuilding Occupmn use cynipmcmoNcvices which emit
Incautiousy �,k�Incautious an,contaminants as defintal by the Boy Area Air Quality Management ageent BOILER-COME(OVER 100.000 BTU) P A 9 V
• District!
❑Yes ❑No NEW RGSIUENTIAI.MECH. SQ.IT, p� o Q
1 have rend the hasardous mmcrials rryuimments under Chapter 6.95 of Ne JT 28 '29Q
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that YV
if the building docs not currently have it tenant,that it is my responsibility to notify the /s
Occupant of the"moments which must be met prior to isoance of a Cenificatc Of 'Cl I I yr vvr CFI I INU
attnpaney.
Owner nr authoriectl eget Doc - TOTAL: ISSUEDBY:
OFFICE