27456 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEU I RICAL PIiRMI'1'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27 /I CLN
BUILDING DIVISION BUILDING PROJEC I[PEN FIFICAI]ON L 4 J v
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DAIli
DR /Vv n, (— 2 ��r—
OWNERS( MR:
PHONE: CONTRACI OR'S NAME: LIC NO:
O .N/C CONIROLN
iCI11'I CT/ENGINF.ER: Ys' LI O: J ADDRESS: O
t
CONTACT: PHONE:
11 Q1 Y. ELECTRIC PERMIT PI3E BUILDING PERMIT INFO
3yP.161! PERMIT ISSUANCE QO BLDG ELECT PLUMB MECII
❑ I ❑
LICENSED CONTRACTOR'S DJZLARATION APPLIANCES-RESIDENTIAL JON DESCRIPTION
Iherebyufr,.that l am licensed undermoG,ionsof Chapler9(cnmmencing with
100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
VV UpUp full force unit effect.
L4,w License Clnss Lia.p UP T021N1AMI'S
y6v, Dam GOOW[lA" 2111-IgN1AMPS
Fy44, HITECI.I DEC.ARATION SQ.FT,FLOOR AREA E/SQ.IT.
OVER 1000 AMPS
Oz—M I amssmnd my Plans shall be used as pthlis records.
P rn�u] SIGNS ELECTRICAL
�j .•..II Licensed PrmfieWnnal
C�Wa OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO, I hereby affirm Thal 1 am exempt from the Contrxcmrs License Law for the
r+$am I'ollnwingrcane.(Section 7031.5,Business and Professions Code:Any cityinstantly TEMP.M=..R OR FOUR INST.
which requires a permit In construct, her.improve,demolish,or repair my struqurt
�WY prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
p=L o that he is licensed mount 1. he provisiowof the Contmemrs License-mv(Chume,
t1 P,4 9(commencing with Section 70(0)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,_,o or shrine is exempt therefrom and the basis for alleged exemption Any violation of
Fd
2_¢ Section 7th an
1.5 by y applicant for a permit subjects the affliction OUTLETS-SWITCHES-
nt to a civil penalty of FIXT'URCS 1 U
yy nal morc,h.five hundred dollars G$50p. .
F� ❑ I,usownerorf Neprt)Nrty,nrmyemployceswithwagesuslhcirsolewmpensaliNIiW RISIDEMTIAL FhF.CPIi on, S QIT. STORIES TYPE CONSTRUCTION
13. willdo the work,and Nestrucmrt isnot intended proffered forsale(See.70414.Business
and Professions Cah:'11te Comracmrs License Low does not apply 10 an owner of
Progeny who builds or improves thereon,and who does such work himself or lluough his
own cmployees,pnevided thmsuch improvements are notinlendiedornffered forsale.IL OCC.GROUP RES.UNI'T'S
however,the building or ntprovemenl is sold within one year ofcompldim,the owner- TOTAL: 3.(�
builder will have the bonbon of proving that he did not build or improve for purpose of
mlaJ.
❑ Las owner ofthe property,em exclusively comructing with licensed contractors to QTY, PI BINGPERMIT x IPE FLOODZONE APN
construct the project(Sec.7044,Business and Professions Code)The Conan...
I.icensel.awdoosnoulpplyroanownerofpmpcnywhobuildsorimpmvesihereonand PERMrp P91ANCE
who contracts for such projects with a conlrectorpo licensed pursuanuothe Conhadors AIT -DRAIN&VENT-WATER FA
License Law. (- ) I MESUMMARY
❑ I am exempt under Sec. B&P C for this cotton ACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner pate DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTX
WORK MAN COMPENSATION DECLARATION SCHOOL TAX Y N_
❑ Thereby affirm that l have a certificate ofcontent to selGluam.or a cenificate FIXTURES-PER TRAP RECEIPT ex
Workars'Comlearawian bouruneeoruanificd copy lherenf Uese.3900,1-mCJw ch PAR aE Y_N
Poers nil employee'a under this pcmtit GAS.FA.SYSTEM-1 4 OLTIT.EI'S RECEIPT M
licy p BUILDING DIVISION FEES
Company GAS-EA.SYST' (EA) PLANCHECK FEE
Certified copy is hereby furbished.
Cenifcd copy is tiled with the city inspcmion division G v SE WASTFrI .RCE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' Ap SOILS FEE
COMPENSATION INSURANCE
Upris section need not becompletedifthepennit isforonehundreddo (SI00I SBW SANIT yNA$ MEA.](0FT. ENERGY FEE
n,leu.)
I certify that in the pedormanceofthe work for whichthis pemtit is issue shot] WAT EATHR NENT/CLECI'R
not employ any person in any manner so u m become subject to the PAID
Z Compensation Lawsol'Culifomia. Date WATER SYSTENFEREATINO Date Recare,N
0 O Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
E y become subject 1.he Workers Compensation provisions of the Labor Code,you most
a .~�-t forthwith comply with such provisions or this permit shall bo deemed invoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby uffimn that there is a construction lending agency for the performance of
U O the work for which this permit is ioucd(See.3097,Civ.C.) TOTAL: ELECTRIC FEE O�
LT. Landers Name PLUMBING FEE
Lcndcr'n Address QT'Y, M: HANICAL PERMIT PEE
L) I certify that F have read this application and slide that the above information is
correct I agree to comply wirhaR city and county ordinances and stale laws relating to PERMIT ISSUANCEOb
7 M17CHANICAI.IEE 3'?.�
� building construction,and hereby solution representative's of this city m enter upon the
U a above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONST RUCTION TAX
(We)agree to ave,indemnify and keep harmless the City of Cu iso against
liabilities,judgments,costs and expenses which may in any way ear gainsisaid City AIR HANDLING ON]TITO 10,000CFM)
in consequence of the an gtif Mtge 1.
AIR HANDLING UNIT(OVER IO,IXMI CFu11
Sigaidurno[ApplicaITContraor Dam EXHAUST HOOD OV/DUCT) PAID ZY
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1(0,000 BTU) Dare Receipt p
Will the appliomr or future building occupant store or handle hauNous material �Iq
u defined by the Cupertino Municipal Code,Output,9.L2,and the Health and Safety HEATING UNIT(OVER 100,1(1)BTU) TOTAL:
Code,Section 25532(a)7
EI Yes 11 No TIVENLATION PAN(SINGLE RESID)
BOILER-COMP pHP OR 1(10.1100 BTU) ISSUpANC ATE
Will the applicant or future buildingoccupant use equipmenmrdevices which emit P M 1 9
hamrd us air communities u defined by the Bay Area Air Quality Management BOILER-COMP(OVLR 100,000 BTU)
Disnim'1
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FI'' -IAN 24 1995
1 have rend the hazardous materials requirements under Chapter 6.95 of the v
Califprda Health&Safety Code,Sections 25505,25533 rad 23534. 1 understand that CI I I yr W YCH 1 INU
if the building does not currently have a tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Carl i Fears of
Occupancy.
Owner-praul6mixedionma ])are TOTAL: ISSU ED BY: "ps-`a"
OFFIC