28115 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OPCUPERTINOIL 1\.- '. C"IRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /] Q C
BUILDING DIVISION IDHN'I'IFICAOON Lo J
B ILDINGADDRESS:L.r G.A SANITARY NO. APPLICATION SUB//MkUTAL DATE
1✓Q UNIT# LOTtt `,-
N SNAME: ` PHONC:: NTRACTOR'S NAME: LIC NO: V
IJ/�'L ✓/N'/(.� 6 0[JrI��/( N/C CONTROL#
•A CIII'I'ECT(FNGINFF:R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CON'1'RAM OR'S DECLARATION APPLIANCES-RESIDENTIAL JOBcpFC C (PTI
F1yZ Ihereby offirmthmnam 3ofth Busised ness ndPrinmionsCarlOfampter 9(commencingwith C e
�00 Sction]Ogl)of Division Jof the Business and Professions Crile,and myliccnsc is in PANELS
�b full force and effect. L
hZ' License Class Lic.itUPT0200AMPS
m<a Dam Coneacmr
F,,z ARCHITECPS DECLARATION 201-RICH AMPS SQ.FT.FTC OR AREA $/SQ.14.
Dor?- I understand my plans sM1Wl be used as public records. OVER IOW AMPS
F w F J SIGNS ELECTRICAL
<��, I.icemcd Nafesvonal
�Mae< OWNER"BUILDER DECLARATION I`UPECIAL CIRCUIT/MISC.
jdOyF I hereby affirm that I am exempt from the Contracmr'a License Law for the Lk
W3Orn following reason.(Section]031.5,Business and Professions Code:Any ci iy or county TE MP.MET ER OR POLE INS'f.
t�y; which requires a permit to construct,alter,improve,demolish,or repair any swnum
,W17 prior m its issuance.also requires the applicant for such Permit o file a signed statement POWER DEVICES
to K G O that he is licensed pursuant to the provisions of the Costractods Lianw Law Chapter
nKC� 9fmmmencing with$ection]U(p)of Divisian3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
W`cart or that he is exempt therefrom and the basis for the alleged exemption.Any viontionof r
F Z� Section 1031.5 by any applicant for a permit subjects the applicant to a civil penahy of OUTLETS-SWITCHES-FIXTURES VR
5S c< not mote than five hundred dollars(5500).
ei ❑ I,asnwnernftheproprcty,orntyemployceswithwugesasthcirsolecompensation, NEW RFSIDIiNTIALF.LECTR _SQ.F`L STORIES TYPECONSTRUCHON
We= will do tM1ework.end the nmcwrc is not inended nrnffereA for sale(See.1B64,Business
and Professions Cash,The Constructor's License law docs not apply to an owner of
properly whobuildsorimprovesthereon.andwhod«ssuchwork himalforthmugh his
howcmployces,provided that such impmvementsare not inrendedoroffeasi forasle.If. OCC.------ GROUP RES.UNITS
ever,the building or improvement is sold within one year ofemopletion,'becomes.
builder will have the burden of proving that be did not build nr improve for purpura of A
.).
❑ Buri the pr flhject property.l,Business
land Professions
Ce icon The Ctm uchn" QTY. PLUMBING PERMIT PEE FLOOD ZONE ApN
mese theprojectnot(Sec.oanonerafsswJy%hobipns Cr imprve Contra,said
License Lvwdounmapplytos with a rnfpropeny whnsed puomint to
Comon,and PERMIT ISSUANCE
whocontainsaeu forsuch projects withuronwetor(s)licensed pnrsuunuothe Conweor's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C fur this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN_
Owner Date DRAINS-FL00R,ROOF.ARECOND.A, RECEIPT
• WORKMAN COMPENSATION DECLARATIONSCHOOL TAX YN
❑ Ihemby affirm thmea
lhavenificate ofcm toonseselG' rc
or FIXTURES-PER TRAP RECEIPT
Workcrs'Compensatinn huurwce oracmifiW ropy tbermf
enc.. as
FEE Y__N
,oversell employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT q
Policy p
Company BUILDING DIVISION FEES
GAS-F.A.SYSTEM-OVER 4(EA)
❑ CenifieJ copy is family famished. PIANCHECK FEE
❑ Ccnlfed copy is fled with the city impecti. division. GRFASIONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEM IN PROM WORKERSGRF.ASETRAP SOILS FEE
COMPENSAT INSURANCE
phis.section need not be comp ifrhelarmaisforoochundreddo arsl$I00) SEWER-SANITARY-$'DORM EA.2WFT. ENERGY FEE..r less.)
lemaylhatmiheperfo aneeoftheworkforeshichthls it is is d,l shall WATER HEATER W/VF.NTpiLECTR
not employ any pl i any mmme,so asst. scene ct b,the orkcrs PAID
z Compensmion laws.1' Britain. Date WATER SYSTEM/IREA'L'ING Dat, Receipt#
Applican
z 0 NOTICETO APPLIC T:IL iter making th' eni , eofFemp should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL'
h f� become subject m the rkcrs Cm sat n ons of the tuba must
ta' 7 forthwith comply with a ch provisi O 'Jkwit shall b BUILDING FEE
y CO STR LFJ q ^ SEISMIC FEE
Z) z Ibcrcby a0imt thou retia sv tion inga ancyh the ormance of
U O the work for which this pe mit is issue vl 30t ) TOTAL ELECTRIC FEE.
Leader',Name
0 U finder's Address QTY. MECHANICAL PERMIT FEE PLUMBING IEE
1 certify that I have re this application and sem t t the aMovc information is
Fr" GW. correct.l agree m comply wit all city andcourev Orth issandstatelowsrclmingm PERMIT ISSUANCE MECHANICAL FEE
IA building cnnstructinn,md here yauthonzc reprcxen ivcsoftbiscitytoenteru,sn Ne
U above-mcntionedprnpcnyfori apcmionpurp^s , ALTER OR ADD TO MECIi. CONSTRUCTION TAX
(We)agree tosave,indent 'fy and keep armless the City of Cupenino against
inbilities.judgmene.consondex nostsw may in anyway acme against said City AIR HANDLING UNIT(TO IU.(yWCFM)
in cousequeg4of the granting of Ur.
' AIR HANDLING UNIT(OVER IQ(IDB CFM)
Signatureof Applicam/Contracmr Data EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)BTU) Dam Rccipt#
Will the applicant or future building.ecupam store or handle lumbers material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the l leahh and Safety I BEATING ON IT(OVER 100dKX)BTU)
Cade,Section 25532(x)?
❑Yes 13 No VENTILATION FAN(SINGLE RESID)
Will theapplicam OrfmurcbuilJingccupum useeyuipmcmordeviceswhichemit BOILER-COMP(3HPOR 100,000 BT1J) II7j��IS$UANCE DATE
• Drum.?Institutioair contamine E ;is Defined by the Bay Arex Air Quality Management BOILER 100,000 BTU) I� A 0 T
D6triat V
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT.
I have read the hazardous Similar, requirements under Chapter understand
of the MAY 22 1999
if the uil ingHisdh s Safety Cale,Senions 2.5505,255.)3 and 25534. I understand that
ifthebuildingduesnotcurrentlyhaveaower,et it is my responsibilityto enotify the CITY
aupa t of the reyuimttenrs which must be met prim m issuance of a Cenificnm of l#
OF UUrrHY r'
occupancy.
owner or emhodmd agent Dae
TOTAL: ISSUED BY:
OFFICE