2730 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CI'T'Y OF CUPERTINO 111111.01 G-LLR•1'RI AL FERMI TNO.
APPLICATION/PERMIT PLUMBING CTIDENI IFIL 27330
BUILDING DIVISION /^��^. BI111.I)ING PRO.IKCT'IIII!N'I'IF'ICKTION
BUILDING ADDRESS: (1-3
QuGCns 'vry wr /' .DGf wo gVt:01/. SANITARY NO. APPLICA'IIDNSUHMI'ITAL UA'Gi
•UNIT# Wr LOT# �I \
O
ERS NAME: PIIONP: CO ACTOR'S NA ' LICNO: L
N/C CONTROL#
V I V BK A5"WINb D R�4"6 61I7�
\RCI II'1'ECI/1iNGINEER: LIC NO: ADDRESS: E]
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ' ELECTRIC PERMIT FEE
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE 1:1 ima,
LICENSED CONTRACTOR'S DRCLARATION APPLIANCES-RESIDENTIALL
pyz I acridly afloat that l am licenxions m
sWnnder pmiof Chapter 9 Enmencino with
t JOIE DESCRIPTION
[WOO Section 7")of Division3of the Business and Professions Code.and my license is in PANELS
y tY 1F—.. full ionic and effect.
6Z, License Class Lie.Is U1110200AMPS
o',�y Date Commefor - 201-I000AMPS SQ.F1'.FLOOR AREA E/SQ.FT.
i ITEM,sARC111TEC1"S DECLARATION OVER 1000 AMPS
Z
OO—p I understand my plana,lull homud es public records.
SIGNS ELECTRICAL
Licensed Profimsioal
OWNER-BUILDER,Isemptfrom DECLARATION ON SPECIAL CIRCUIT/MISC.
OaO 1 hereby nil(Se that I am exempt from he Contractor's License Law for the
3LLy fohichodmimair permit to 7031.5.lumarmel, her.
aJ Professions CWe:Any city nr county TEMP.METER OR POLE INST.
fSO; which its issuance,
permit Int tlmmrthe mleq improve,demolish,nr repair any statement
;!INS triton,licensed pulsortqui the
theapplicantof the Co permit's file a License
La (Clasper POWIiR DEVICES
ty..4p thusheislicensWpursuantmthe).f Division
the Contactor',License Law(Chapter
SWIMMING POOL ELECTRIC kp 9(eoth,is iscorth Section
nandthe Division 3ofthe Baines, s hladmim' VALUATION
Wim orlhm h,is rps,..is for theallegedmhoucainn. civil
of
H'7¢ $ev'linn]03156y any applicnntforalwrmit aubjena the aPPllmmltoaeivVl pnnnlry of OUfl.l3'PS-SWITCHES-I�IX'I'URES
e than Eve hundred dollars($5011). NEW RESIDIiNT1A1.ELI!CfR _SQ,F1'.
��m I,asownernfNepro,,,y,ormyemployeeswith wagesmlheirsnlecompenmtion. / S 1 TYPECONS]RUCIION
a32will' he wad,and theswcmrcisnotimendW ornffcrtdfor sale(Set.9044,Business
and Profoasinnx Code:The Contractor's License Low does not apply to on owner of 1 - J
prolway who builds or improves themon.and whodues suchwork himselforthroughhis OCG GROUP RES.UNITS
owdemployces,provided Nw
at suchimpowcoents enn intendedoroffercd forsale.if,
however,the building orimprovemem is sold within one yearof rompledmn,the owner- .OT.
builder will have the burden of proving that he did not build of Improve far purpose of
sale.).
❑ I,asowmerof Neproperty,amexdusivelycommeting with licensed emunclom to QTY. PLUMBING PERMIT FEE FLOODZONE AI'N
connWR the project(Sec.7044,Business and Fadession,Code)The Contractor's
License Luwdncs nm a pplymmnowacrnfproperty who builds or improves thenen,and PERMIT ISSUANCE
who onamd,lin such projects willn connacmns)licensW panacea mine Commemh
License Law. ALIPR-DRAIN&VENT-WATER BiA) FEE SUMMARY
❑ I am exempt under Scc. ,B&P C for Nis meson BACK FLOW PROTECT,DEVICE I SIDE '
SANITARY Y N
oll Owner Data RFCEIFI'#
DRAINS-FLOOR,ROOF.ARTA,GOND.
WORKMAN COMPENSATION DECLAIIOOL TAX Y N
❑ iherchy affirm tha'Ihave eremitical,of tenuu
os uibinv ONSCl!-insure,ma cenificwe of FIXTURES-PER TRAP RF.CF.IFI'p
/Workcrs'Compotsution lnsnruneo orncemi0ed copy thereof(Sec J9Bd,Lnb CJ which PARK ITC YN
ca all emploYec's undenhis permit GAS-EA.SYS'THM-I INC.4 GUILE I'S RECEIFI'#
Policy It BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHF.CK ITE
❑ Certifiedemyisheebyf nd,hW,
❑ Crohitdcnpy is fled wi0uhe city inspec'inn division. GREASE/JNDUS'I'LIE WAS'Di INTERCEPTOR GRADING#iii?
CURT IFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(I'hiauenionncednut becomplucd il'Ihepccand is format hundred dollars($100) SEWER-SANITARY-STORM EA.2WIF T. ENERGY FEE
or Ices.)
I cenifythm in The perfmrmace ofthe work for which this permit is issued,l shall WA'T'ER HEATER W/VW- OHLECR
not employ any Person in any manner sus as to become subject to the Worker' PAID
Cmnpcnmlinn Lnws of Cnlifnmiu. Dom WA'IERSYSTHM/TREATING Date Receipt#
C) z Applicant
z0 NOT'ICF.TO APPLICANT:If.after coding this CeniOcwe of Emurinmm.,you.humid NEW RFSIDIN['IAL PLMB. SQ.FT. TOTAL:
(q become subject o the Worker's Compensation provisions of the labor Code,you most
jfnrhwitb comply with such prwisimsor this permit shall he deemed revoked. BUILDING]:[;I,
0. ❑ CONS'IRUCDON LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that them is a construction lending agency for the pedotmunce of -
Q the work for whlcli this pcmtit is issuW(Sec.309],Civ.C.) 'I'O'1'AL: ELECTRIC FEE
header's Name
U•' F' Lender's Address '-= -"- ^ ` QTY. MECIIA NICA E PERMIT FRE PLUMBING ITB
0 U 1 certify that 1 have read this application and state that the above information is MECHANICAI•FEE
a.4t7 roost'.lugrce it) with all city and county ordinances and acme laws relating to r PERM IT ISS DANCE
U z building curn,hant on.and hereby amhorircnitmiumuuives of this ci ty to enter upon the CONSTRUCGONTAX
above-mentioned Property for inspection purposes. ALTER OR ADD TO MSCI I.
(We)dome to save,indemnify and keep hamdess the City M Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO 10,000 CFM)
in vonsequence nl the granting of this perimi["''
II 2-3 1dlAIR HANDLING UNIT(OVER 10,000 CFM)
Tom of ApplicanVContntnm Date EXHAUST 11001)(W/DUCT)
PAID
• HFAI'ING UNIT(TO HILL"BTU) Data Receipt#
Int or home
building MATERIALS DISCIASURL
Will the the ClantorfuMuniciCode,Cater 9.o,handle and
aealthadous Safety HEATING UNIT(OVER I FILM BTU) TOTAL:
u dcOnW by the Cupeninn Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(a)I VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(MIT OR RAM BTU) ISSUANCE DATE
hurelWill Nedjrplicant or fommbuilding rwcupatu.0<quipmem mrdevices whichemit P1 Ik ' n
as elr conwminars na da0nul by the Buy Aru Air Quality Manugomem BOILL'R-COMP(OVER 101.000 B'PU) P /M D
District'? 23 1994❑Ya 1:1 No NEW RESiDEMIALMECII. SQ.FT.
• 1 hove mad the harnnlons materials requirements under Chirpier 6.95 of the NOVN
Cnlili!r is Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have aaccord,that it is my mapnnsibility to notify the Ci11Y Or Irl'[ )
accupam of the requirements which must be met prior to issumce of a Cmiricate of
Occupancy. V L '
Owner or amhorized agent Dole � ISSUED BY:
OFFICE