27365 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOOILn;oui- r.,mIC PERMITNO.
APPLICATION/PERMIT PLUMB NG-MECHANICAL 27365
BUILDING DIVISION -BUILDINGPRO]ECT IDRNTIFICADON '
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
21723 EG ART CT. UNIT# LOT#
OWNERS NAME: - PHONE, CONTRACTOR'S NAME: LICNO:' -
N/C CON"rROL#
ARCHITECT/ENGINEER: LIC NO: ADURBS: ❑,
63 4090PAR-P kr?,
'ONTACT: PHONE:'.-
QTY. ELECTRIC PERMIT, FEE BUILDING PERMIT INFO
BLDG ELECT 'PLUMB SUCH
' PERMIT ISSUANCE El 0 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL yC JOB DESCRII'1'ION '
Qo4z I hereby affirm that l am licensed under providonsmChapw9(commencing with
u100 Sec'ion7000)of Division 3ef the Easiness and Professions Code,and my license is in PANELS
FC fullullforce and effect. L
d,ZUz,W ,Class Lic.# - UP 70200 AMPS
rFii6tA Data Contmetor 201�1OW AMPS
ZO sn Pa ARCHITECT'S DECLARATION - OVER 1000 AMPS SQ.FU FLOOR AREA - $/SQ.FT.
0'L•., I undcn and my plans shell Proved as public records.
1;,rnF� SIGNS ELECTRICAL
Licensed Professional
SSV
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. -
°ktOyF 1 hereby affimc that 1 an exempt from the Cnnuactors License Law for the
Fwt following reason(Seuion]03 L5.Business and Professions Code,Any city or coumy TEMP.METER OR POLE INST.
e which requires a permit o construct,after,imp rove,demolish,or repair any structure
2 } prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES '
�GO 'hal he is licensed pursuant to the provisions of Contractor's License Law(Chapter
e.p,o 9bru meneing with Section 7000)of Division 3 of'he Business end Professions Code) SWIMMING POOL ELECTRIC D y A9
on car that he is exorepuherefrom and the basis for the alleged exnmp'im,Any violasion of OUTLETS- ITCHES-FIXTURES 4
SW
4 Section 7031.9 by anyapplicantfor a permit subjects Be applicant a civil penalty of n -
G
n 'mom than five hundred dollars($500).
0 ❑ 1,asownerofthepropeHy,ormyemployeeswilhwagesaslheirsolecompensetion, NEW RESIDENTIALELECTR _SQ.FT. ISIORIES TYPECONSTRUCTION
y3_ Mildothework,andthestructureis nolimendulorofferul for sale(SecJM4,Business
and Professions Cede:The Commclor's License Law does not apply to an owner of ,
property whobuilds orimprrves thereon,and whodocs such work bimselror lhroogh his
hoemployeae,provided ihmwchimpnrvemenfsarcno'Imondnd6rof[ereJ forsale.If, OCC GROUP RBS.GNITS
wever,the buildingor improvement is sold within oiie year ofeompletionJheowner- TOTAL: '
builder will have the burden of proving that he did not build or improve for purpose of ,
cele].
❑
construct
the project
(Sec.7044.Business
and Preeetiions C licensed Contractor's
QTY. PLUMBING PERMIT FEE FLOOD ZONE qPN
License the project apply
o Business and ywho build Code:)The Comraoroe§ -
whoceLawtleesnotapplyto with a crofproperty whosed pursuant
to the Corson,and PP.RMI'T ISSUANCE -
whoconlmcts for such projects with acnntmelor(s)liceneed porsuannolha Cnmmaors
License haw. ALTER (EA)) EEE SUMMARY "
❑ 1 am exempt under Sea ,B&PC for this reason - OUTSIDE FEE
BACK FLOW PROTECT,DEVICE
SANITARY YN
Owner - Data DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
' WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
:❑ Ihaeby affimvhmlhaves ceniBcate o[consem to sol f-insect,oraconiRram of FIXTURES-PER TRAP RECBIPT#
Workers'Compensation Insurance or Prettified copy thereof(See,3800,Lab C.)which PARK FEB Y N
nv rs all employee's under this pemil
GAS EA.SYSTEM- INC.40U
Policy# BUILDING DIVISION DIVISION
PEES
Company GAS-EA. . 4(EA) PLANCHECK FEB'
❑ CenifiW copy is hereby famished.
❑ Cenilied copy is filed wiN Ne city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR
FADING FEE 1' i
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP S LS FEE
COMPENSATION INSURANCE
('This sectionnearlmn be completed This,permit is for one hundred dollars($100) SEWER-SANITARY-STORM °A.
Pass.) 200PI'. EN GY FF.F. -'
o -
Icenifythat inthe performanceof'he work for which this permit is issued,Ishall WATER HBATER WNENT/IiLE
not employ any person in any manner so us to become subject to the Workers'
Compensationlawsof Callfonda. Date WATER SYSTEMITI REA�Ny Dale ReceiplN
0 Z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL P FT.
IZ) become subject to the Worker's Compensation provisions ofthe Labor Codem
,youost TOTAL:
� ; forthwith comply with truth provisions or this pe.,I shall be deemed owns ed. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz Ihercby affirm thatthere is aconstruction lending agency for the perfornanceof'
O the work for which this parted is Issued(Sec.3097,Civ.C.) TOTAL ELECTRIC FEE
Lenders Name
U 1<nder's Address - Q MECHANICAL PERMIT FEE PLUMBING FEE
I versify Nut 1 have mad this application and stare that the above Informulion ie
correct. I agree to comply with all city and county ordirseeesand slate laws relatingm RMIT ISSUANCE MllCHANICAL FEE
�' In huilding oonstmetlon,and hereby auNorize represen'advesof this citymentu upon'he CONSTRUCTION'1'AX
U above-mentioned properly for inspection purposes, ALT. OR ADD TO MECH.
'(We)agree to save,indemnify and keep herandas the City of Cupertino against
liabilities Ldgments,cosIsand exswhich mayinany way accrue against said City AIR HAN GUN 1<1 0,000 CFM)
moo e( oeof0egreedng of 9permb.
AIR HANDLING UNIT(OVER Ig000 CFM)
Signamreo Appl' t/Cnmrua d D(ate—/ EXHAUST HOOD(W/DUCT) ,
PAID
.HAZARD MATERIALS DISCLOSURE HEATING UNIT CIO IOO,IXHI BTTU Date RvcnlptN
WI 11 the appllcanl on fat beileing Pecupvm eesre or handle hazardous mvtedel ABATING UNIT(OVER 10U,000 BT11) TOTAL:
as defined by the Cupertino Municipal Cotle,Chapter 9.12,somme I]catch and Safety _
Code,Section 25532(a)?
11Yea 0 N VENTILATION FAN(SINGLBRB9I D)
BOILER COMP(311P OR 100,000 BTU) ISSUANCE DATE
Wl applieanmrfumrehuildingrccupxm useequipmem emit A Y PT+
hazardoilus the air mdevdceswhixh conWminapas as defined by the Bay,Area Air Quality Management 100,000p01LER-COMP(OVER 100, pTU
District?, - )
❑Yea ❑No NEW RESIDENTIAL MF,CU. SQ.FT. (�(�[
1 have rend Ile hmMAR 1
anlous materials requirements under Chapter 6.95 of the - , MAR 995
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that JJ''
if the building does not currently have a tenant,that is is my responsibility to notify the Vr vUl'ILrl i 11 u
occupant of the requirements which must he met prior to Issuance of a Certificate of
Occupancy.
Ownenaamhcrized agent Date" 'TOTAL: ISSUED BY:
OFFICE