27021 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ImtLbirpi I LRc'rrR PERMITNO.
BUILDING DIVISION 0
APPLICATIOVIarRMIT' PLUMBING-MECHANICAL.
- BUILDINGPROJECTIDENTIFICADON
BUILDINGADDRF.SS: SANITARY NO. APPLICATION SUBMITTAL DpppATE
23 C-*: . UNIT4 Lop# /641-,Rt
OWNEIiSNAME: PHONE: CONTRAC'I'DR'SN LIC NO: NIC !!{ CONTROL If
1A+ate. { (�c�i I Ou 3151 G P 9D5`
RCI I I I LCT/ENGINEF.R: LIC NO: - ADORES S: -C'• /(, �v u�r
;ONTAcT - PHONE: V J /OiI' BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT- FEE
BLDG ELECT LOMB MECH
O 1 PERMIT ISSUANCE El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby ffirtn(but l am licensed under !Chat 9(commencing JOB DESCRIPTION
p y y Y a uld Profes0 per add
mmenoln with
100 Sectionorce ad of Division ofthe Business and ProfcssiOns Code,cad my license la in ppprHlg
y¢� fillLie Toreson,,_!feet.
FUW Licease Class Lia.# UP T02fI0AMP5 t '
w y pec Contractor 201 1000 AMPS -
Z FO y^ ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr. -
Oz—,0 l understand my plans shall be used as public records.
Py ia SIGNS ELECTRICAL
;� LicensedProfessional
OWNER-BUILDER DECLARATION SPECIALCIRCUIT iSC.
O F 11 by fl m,Thal 1 um exempt fir (ha Contractors License Law for the
0mfollowing re....it,Section III S,Business and Professions Code Any citynr county TEMP.METER OR POLE INST.
�tnJwhich q a s Permit m construct alter,'mpm demo]ish,or repair any structure -
w'>+� prlorlo Is issuance,also requires the applicant forsuch permitto file asigneddrisanent POWER DEVICES
W 00 that he is licensed parsuanuo the provisions of the Contractors License Law(Chapter
m•�o 9(cemmencing with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION '
Wim or that he is exempnherefrem and tire basis for the alleged exemption.Any violation of
a
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of OUTLETS-SWITCHES-FIXTURE
not more then five hundred dollars($500).
_A p ❑ I,as mwnerof(hc property, wages as theirlem „ NEW RESIDENTIAL LE S . STORIES
TPcopensationCTION
will do the work,and the structure is not intended or offered for said(Sec.9044,Business
and Professions Code:The Connacror's License Law does not apply to on owner of
property who builds or improves thereon,and who does such work himself or through his
employees,providedthn(sncltimprovemen(sumnotlntendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement Is sold within one year of oomplefioo,Ibeowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). -
❑ 1,asownernfthepropeny,amexclusivelycontractingwithlieenseacmntr wrsio QTY. PLUMBING PERMIT PER FLOODZONE APN
consorted the project(Sea.9044,Business nod Professions Code)The Comracmr's
License Lawdoes not apply to an ownerofpropenywhobuilds orimprovestberma,and PERMIT ISSUANCE
who contracts fursuch projects with a monsoonal)licensed pursuant mthe Crntracrors ALTER ( ) FEE SUMMARY
License Law. WATER EA
❑ I oro exempt under Sec ,B&P C for this mason BACK FLOW PROTECT.DEVICE O TSIDE FEES
SANITARY YN
Owner Date - DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
1 40❑ Thereby af0rm thatlbavea certificate of consem t0 self-insure,orecenificme of to FIXTURES-PER TRAP RECEIPT#
Workers'Cnmpensntien lnamoded o,a terrified ropy(hefeof(Sea.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTF.M-1 INC. ECEIPT#
Policy# NC.40UTLF.IS BUILDING DIVISION FEES
.Company
❑ CeniFled copy is hereby tumbled. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is fled with the city inspection division. GREASFJINDUSTRL WASTE IN'PLRCEITOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section neednot IN camploed ifthe .it is forma,hundredd.11.(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY PER
or loss.)
I certify that in performance of the work for which this permit is issued,I shall WATER HEATER W/VENTTLECI'R
not employ any person in any manner so as m become subject to the Workers' PAID
Coirproomnn Lawsof Califnprou Data WATER SYSTEMOIREATING Dale Receipt If
Applicant
z0 NOTICE TO APPLICANT:if.after making this Certificateof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TO IAL
Hy become.mbjectmthe Worker's Compensation provisions of the Labor Code,you must
t,~-t forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEF.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z1 hereby affirm ran there is a construction lending agency for the perfonnanoe of -
(� O the work for which this Permit is issued(See.301 Civ.C.) AL: ELECTRIC FEE
Leaders Name
ULeaders Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEMF 1 certify that I have read this application and state that the above information isMECl1ANICAL correct.lngrcen comply with all city and empayoNrioncesands(a(e lws relatingm PERMIT ISSUANCEbuilding cmdication,and hereby authorize representatives of(his city to enterupon the
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIO(We)ogee to save,indemnify and keep harmless the City of Cupertino againstIiabilities,Judgmeats,on is and expe which mayin any wayaccrueegeinnsaidCityAIR HANDLING UNIT(IO 10,000 CPM)
esof thtingr noir. AIR HANDLING UNIT(OVER 10,000 CFM)
!p ;3f-y ate fApplic C .cmr - Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE IJHATING UNIT(TO I SLO00 BTU) Dot
Will the applicant or future building occupant sem or handle hazardous material HEATING UNIT(GVHR 100,1100 BTU) TOT
ar defined by the Cupenin0 Municipal Code,Chapter 9.12,and the Health and Safely
Code,Seeh❑Yson 32(a)� El No VENTILATION FAN(SINGLE RESID)
Will thea lieamorfutureboldin Don equipment BOILER-COMP(3HP OR 100,000 BTU)
ISSUANCE ATE
UP, goccu fusee ui torde'vices whi<hemit
hazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) , q f
District? _
❑Yes ❑Nn NEW RESIDENTIAL MECH.—SQ.FT. OCTl
1 have real the theatricals materials regairemerns under Chapter 6.95 of(be G7 I��
California Health&Safety Code,Sections 25505,25533 and 25534, lunderetsnd(hat a I
if the building dros no(curently have n Icnunk that h is my resrymsibiliry ro nmify the /S%
Owupant of the requirements which mus(ho met prior to Issuance of a Certificate of N
ccupancy. p /1- Ur
Owner m ciamdeul egenl - Data TOTAL: ISSUED BY:
OFFICE