27728 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDING-LLL,I H[CAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n n p
BUILDING DIVISION BUILDING PROJECIADERT TcATION L L O
BUILDING ADDRESS: 11 CJ/!7 SANITARY NO. APPLICA'nON SUBMITTAL DA'Z'E
M
�L U Tis LOT#
NnMI:. E CONTR OR'S NA LIC NO'. 1•
C7 N/C CONTROL#
•ARCHIIEC / GINEER: LIC NO: ADDRESS: ❑
CONTACT: PRONE: - BUILDING PERMIT INPO
QTY. ELECTRIC PERMIT PEE
�"B5 ,
L�DGLECT PLUMB MECI
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
rFS<.,UZWyI
mcndog with
1400 SectonfDisision3 ofthe Business and Professions Carle,analny license isin PANELS ^�
_m4yyO�A
fall horsetail effect.
License
Class Lic.p UP T02W AMPS
to=y Dam Connector 201-1000 AMPS
zOyZ ARCIII'rfiCTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O z^p1 1 understand my plans shall he used as public neons.
r 4 ,kSIGNS ELECTRICAL
Licensed professional
wiaQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
XX40e. 1 hereby affirm shat 1 em weeps from she Convect. License Law for Ne
W3LL,q following reason,(Statham 703 U5,Beside.and Professions Code:Any city.,county TEMP.METER OR POLE INST.
�tS� which nature,n pnrtnil to consumer,am
met, en rovrep
impe,demolish,or air any swnme
.E. Y� prior m its Issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
that he is licen.uA pursuant to the provisions or tiro Contractor's License Law(Chapter
GLx o�'
so,...meaning with Section 7000)of Division 31fthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is eacmpnherefrom andfle basis for lheellegcd exemption.Any vio1.1mnof OUTLETS SWI1'CtIES-FI%TURPS
F-ZQSection 7031.5 by anyapplicad fur.permitsubject.lhe.pplicanno.civil penalty of
ore than Eve hundrcddollun(SSW). NEW RESIDEN'11ALELECIR _SQ.FT.
� � w I,asowncrnftheproperty,ormycmployecswith wugesasthahandemmpmandon. STORIES TYPE CONSTRUCTION
LL olhe work,undthe structure is noti,endedornffered for sale(Sec.]044,Business
-. and P delinns Code:The Connector.,License Luw docs not apply,an owner of
Property whohuildsor improves mancon,an l wh,does such work Mmulforthroughhis
ownmployces,pmvidMffiatsuchimprovemenisamnaiintendMoroffmdformic.If, OCC.GROUT' RES.UNI'T'S
however,the building orimprovcme,is sold within oneyerraf completion,the owner-
builder will have the burden of pmving that he did not build or improve for purpose of
sale.).
❑ I,as own.ror,he property,am exclusively connecting with licensed contmclorsto QTY. PLUMBINGPERMIT FEE FLDDD LD F. APN
answer the project(See.7044,Business and Professions Code.)The Contractors
License Law dons not apply loan ownerofpropeny whobuildsnrimproves thereon,and PERMIT ISSUANCE
who contracts for such projects with a mnwctods)licensed pursuant m the Co,ecmr s
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em exempt undo Sec. B&P C for this rtason BACK FLOW PROTECT.DEVICE UTSID,
SANITARY Y_N
Owner Dam RF.CF.IPI'#
® c. re.o DRAINS. R.ROOP,AREA,GOND.
WORKMAN COMPENSATION UIiCLARATION SCIIOOL'1'AX YN
❑ Iherehy affirm than l have u cenifcmeo 'eamem lou re cenlficate of RECEIPT'#
Worker'Compereution Insurance or a cenifiedc FIXTURES TRAP
copy cnf(Scc.3fl00,lsb CJwhich PARK ITE YN
null employee's under this rennin. GAS-EA.SYS ZINC.4 OUTLETS REM.Vr#
Polcy# BUILDING DIVISION ITES
Company GAS-EA.SYSTEM- VER4(FA) PLANCHECK FEE
❑ Genital mpy is hemby[urnishcd.
❑ CendiedcnpyisfEd wish the city inspe iondivision GREASEANDUSI'RL ASTBINTERCEPi'OR GRADING FEB
CERTIFICATE OF EXEMPTI NFROM RKERS' GRP.ASETRAP SOUS FEE
COM PEN SA'r10N SURA _
(This section need not be completed ifthe pedis fo I SEWER-SANITARY STORM FA.20017. ENERGY FEE
.r less.)
I erml y lhat in the performance of the we for which ihi pmail is is s ,Isbell W RHF '�RW ENT/LLECTR
not employ cry person in any m to becomes ject to th 1,- PAID
Compensation Lawsof Califaran.manner
eo a Wq R YS /,T TING Data Receipt#
p z Applicant
Z 0 NOTICEI'O APPLICANT:If.after making thi Cen'Ecam of Exemption.you should NGW RESIDE AL LMB. SQ.FT. TOTAL:
rV) become subject to the Workers Compensation Is visions of the Labor Code,you must
a 1 forthwith comply with such pmvisinns or pe it shall he deetned revoked. BUILDING ME
0. Q CONSTRUCTIONLENDIN AGENCY SEISMIC FEE
z Ihmen affirm that there is a mmonction lend gegency for the pecarrumneW
U O Ne work for which this permit is issued(Sec.309],C .C.) IiLECiRIC FEE
Lender's Name PLUMBING FEE pLende,'s Address QTY'. MECI IANICAL PERMIT FEE
U I certify than I have rad this application sad state than the above mforeaminn is
amorect. ingrec lu comply will,all uityinlemeny ardinenosand sem laws refilling to PERMIT ISSUANCE �� MECI IANICAL FEE
N building construction,end hereby authorise representatives ofthiscity tcenter upon the 1
CONSTRUCTION TAX
U z stave-inertioral property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless Ilse Ciry of Capeni It against
Iiabilities,j a;H�A� RDOUS
ose,MexpenuswNchmaym,ply.v4ggecc�sfyq. #ap iry AIR HANDLING UNIT(TO 10,(100 CFM)
In antes me deom'Idthispenad. �IIJy�J (�`
AIR 14gNDLING UNIT(OVER 10,0#10 CEM)
14
gnawre of pplamednr Date EXHAUST HOOD(W/DUCT) -
PAID
b IAfS DISCLOSURE HPATING UNIT(TO UK,"BTU) Date Receipt#
Will tharrodicart or future building occur.,sere or handle haefdom materiel HEATING UNIT(OVER 100,00E BTU) I'OTAh:
as defined by the Cupenin.Municipal Code,Chapter,9.12,and the Death and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RISID)
❑Yes ❑No 1
ISSUANCE DATE
Will the u munlornsasdaildin cunt, ay mualityMearge ant BOILER-COMP(JHP ORIW,OWIITU) P A I D
pp hoc p rquipmcn
District? it cnntaminanls as defined by the Bey Area Air Quality Menegement BOILER-COMP(OVER 100,000 BTU)
District?
LIlealth
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. DEC 1994
have read the hueadous materials requirements under Chapter 6.95 of the
eallh&Safety Code,Sections 25505.25533 and 25534.1 understand thang does non curtemly have.moans,ohm it is my rtsponsibiliryn.omits the CITY Ur the m pauxur nts which mus,be met prior to I....ofs Certificate of
hnriaed agent Date T L: ISSUED BY:���
OFFICE