27192 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPFRTINOUP 1 -ELECTRl A. PERMIT NO.
APPLICATION/PERMIT PLUMING-MECHANICAL 27192�Q �n
BUILDING DIVISION BALDING PROJECT IDENI'IFICAI'ION 1 G
9U1L GADDRF.: rys SANITARY NO. APPLICATION SUBMITTAL DATE,
peo-styv UNIT# LOT# /�•�x
OW NAME: PH ? C A TOR'S NAM& •1 WC NO: N/C L IJCOKI'ROL#
WC- H ,i l i Gro t J M6• fol 3
ARCHITF.CfAWGINEER: LIC NO: Df E Li .5 C4 Il
CONTACT: PHONE: Q'I'Y ELIiCTRIC PERMIT' FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ I] ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPI'1 N
OKy lherebyaffirm Natlemlicenwdunderpmvisiom.f Chaptcr9(co mcingwiN
POO Section 700(8 of Division 3 of the Business and Professions Cade,and my license is in PANELS
full humanoid effect. UP TO 20 AMPS
<Z, License Class Lic.p sl
EnDy Oam Contractor 201-IMul AMPS
Z FOy�. ARCHITECTS DECLARATION OVER HIM AMPS SQ.FT.FLOOR AREA $/SQ.FT.
1 understand my plans shall be used m public records.
F4)=1a1 SIGNS ELECTRICAL
Licensed Professional
K a,a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
MU affim I hereby rto hat I nexempt from he Contractor's License Law for the
' 1.11mvingretemn.(Set 7031.5,Bminessand Professions Cade:Any city.,county TEMP.MITER OR POLE INST.
F�O l which requires a Permit construct,alter,improve,demolish,to repub say stroolm.
!!ZY� pri.no its issuance,also requires theapplicont far such Permit o file a signed soomem POWER DEVICES Elk
that he is licensed pursuant o Ne provisions of the Contmcmrs License Law(Chapter
9(commencing with Section TIDU)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y1_y or he is exempt therefrom and the basis for the alleged exrmption.Any violation of
1=?,a Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of OUTLETS-SWITCHES-FIXTU
not more than B.c hundred dollen(550().
[I1,asownerofthepmpc y,ormyemployeeswithwagesmtheirsolecompensation, NEW RESIDENTIAL LLE 5 STORIES TYPF:CONSTRUCTION
will Jothework.undthestmaureisn(itimcndedorofferedforsale(Sec.9044,Business /
noit Professions Code:The Contmccols License Law does not apply to an owner of OX
pmpe whobuildsnrimpmvesthercon,ondwhndoessuchworkhimmlforNmughhis OCC.GROUP RFS.UNITS
own employes,mnv idM that such i mpmvemems em not intended or offered fm W e.If.
however,the buildingor impmvemem is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mownerofthe property,amexclusively contracting with licensed contactors to QTY. PLUM PERMIT FEE Fl.DDD ZONE APN
comnuct the project(Sec.]044,Business and Professions Code:)The Contractor's
License Lawdosnm applyinmownerofpropvywhobuildsnrimpmvesiherwn,end PERMIT ISSUANCE ,--
who contracts for such projects withcomracror(s)licenced pursuant to the Conambou's
License Law. ALM-DRAIN&NEW-WATER(PA) FEE SUMMARY
❑ 1 em caempt under Sec. ,8&P C for dus mason BACK FLOW PROTECT.DEVICESANITARY OUTYI N
Owner Dam DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT'#
•
WORKMAN COMPENSATION DECLARATION SCf10(11.TAX YN
❑ Ihere"taprim that l have aeorifcum ofcOsenttoself-insure,ma cenificeteoFIX
f RECEIPT'#
TURES-PER TRAP
Workers'Compenmtiun Insurance oracenifial copy Hereof l5ec.78W,Lab CJ which PARK FEE YN
cere all employe,a under this pcm _
tit.
GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTE1,FOVER 4(EA) PLANCHF.CK FEE
❑ Certified copy is hereby famished.
❑ Cenifiess copy ie filed with the city impenion division. GREASMNDUST'RL WASTE INTERCEPTOR GRADING FER
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSA'T'ION INSURANCE
(This section acedma be completed ifthe N.it is feature hundred dollars(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
mlcssJ
Ice int perform sof rk fm which this permit is issued,I sholl WATER HEATER W/VENT/ELECfR
n t carpel Y p m in a m to become soh' PAID
.tion( na' mmia nc O crs WATER SYSTEM/1'RPATING Date Rttcipt#
pz A
Z U NOTICE' APPLICANT:ILam,making this 6mfcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
FCI)L. hecu subject the Worker's Compensation provisions of the labor Code,you must
:4 far ithcomply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FRE
z I hereby affirm that hem is a construction lending agency for the performance of T ELECTRIC FEE
V O the work for which this permit is issued(Sher.3097,Civ.C.)
Lenders Name PLUMBING FEE
:T. F Lender's Address QTY. MECHANICAL PERMIT FEE (01
V I certify but 1 have read this application and state that the above information is
�" 1 correct.Iegree wenmply with ell city and cnunry ordinances unJ smmlewe rclatingm PERMIT ISSUANCE MECHANICALFEE
rA building cousbactim,and hereby authonre rcprommatives ofthiscity to enter upon the CONSTRUCf10N TAX
U Z above-mentioned property for inspection properms. ALTER OR ADD TO MECH.
(We) meor save,indemnify end keep hmmiss the City of C.,mam agzfmt _-
fiabnhis,jud tsandexpenscswhichmayinanywayaccme against said City AIR HANDLING UNIT(TO 10,0130 CPM)
SrIEein cosof eginwf this it. AIR HANDLING UNIT(OVF.R 10,M)CFM)
tof ApplicanVCrmmancrtm I~ EXHAUST HOOD(W/DUCT) PAID
te r
ZHAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dme Raeipt#
Will the applicant or future building acupart score or hudle hawdous material
a+defined by the Cupertino Municipal Code,Chapter 9.12,and the Hari end Safety HFATING UNITIOVER 1040013 BTU)
Code,Section 25532(a)9 VF."LATION FAN(SINGLE RESID)
❑Yes ❑Na
Will theapplicam or fuwrehuilding Occupanmseequipmem nrdevicswhich emit
BOILER-COMP(31IP OR I W,f100 BTU) ISSUANCE DATE
•Uaaerd.us sit contaminants u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 180,000 BTU) P A 9
t
❑Ys ❑No NF.W RESIDENTIALMECH. SQ.FT. OCT h%1as
1 have mad the hormones materials requirements under Chapter 6S5 of the 19w
Culifomia Health&Safety Code,Sections 25505,25533 and 25534. I understand that
i f Nc hnildingdoes not curren0y It...ammt,that it is my respmsihility to nmifythe CITY Ur l#urt
cupant of the requirementsst h
which non met prior to issuatt uof.Certifite caof
Occupancy. s
Owner m embodrN agree Date TOTAL: ISSUED BY:
OFFICE