27925 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPESION PLUMBIINNG-MFBLCN NICAI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECT IUEN'1'IFICA'1']ON 27925
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMfITALDATI
I+c s UNIT# LOT#
O ERS M r PHONE CONTRACTOR'S NA LIC NO: `
alp ao si ` / 'e, N/C CONI'ftOL N
ARCHITECT/ENGINEER: LIC NO: ADDRFC
CONTACT: PHONE: QT-y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LE EC[ PL_UMy MECH
PERMIT ISSUANCE /� 'LCL/r
LICENSED CONTRACTOR'S DECLARATION 11 pppLIANCES-RESIDENTIAL ��
I hereb ffirn that lam licensed under JOB DESCRIPTION
GKZ Yu provirfesio Chapter an mmnrnense wird
x100 Section 7")ade f Division 3.(the Business and Professions Cade,and my license is in PANELS
FCU full forceCl.—fect.
QZ W License ClanLIC.N IIP TO 200 AMPS
N=y Dote Convector 201-1000 Ah/PS
z y Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
C Z^ I undemenJ my plans shell be used es public records.
F 4 ; SIGNS ELECTRICAL
,� Licensed Professional
i WcxU OWNER-BUILDER DECLARATION SPECIAL CIRCUFDNIISC. J�
xxbyF 1 hereby affirm that 1 am exempt form the Contractor's License Lew for fie
W 3 O m¢ following o mown.(Salon]031.5,Business and Professions Cade:My city r county TFNMP.METER OR POLE INST.
IS m.] which requires a permit to construct,alter,improve,demolish,or repair any structure
�WY7 priorto its ismard",a,sorequires the applicant for such perturb file a signed statement POWER DEVICES
E G p shut he is licensed pursuant to the provisions of the Contractor'a License Law(Chapter
aKe�' 9(emnmcncing with Section 900(1)of Division 3ofde Basis.and Profanimu Code) SWIMMING POOL ELECTRIC VALUATION
W-„n or that he is eaempnherefrom and the basis for the alleged exemption.My violmion of / ♦ r�
�ZQ Section 2031.5 by any applicant for a permit subjects the applicant to a tivil perWty of -SWITCHES-FlXTIJRES PFEE
{Is /`-9
not mom than Gvc hundred dollars(S50). j
� � ❑ I.axownerofthe poopeny,ormyemployaswish wegesutheirsolemmpensauon, NEW RFSIOENtIAL EI.ECfR _SQ.Ff. STORIES TYPE NSTRUCTION
a Yrs will do the work,and the structum is not intended or offered for solo(SecJ04#,Business
and professions Code:the Contractor's L' ase Isco does not apply to an owner of
pmpenywhobmIdaorimpmvesther. ,mdw od"'such work himself.,through his
own employees,provided Net so mprovemm a...innenddoroffcrd fmsale.H, OCC GROUP CoRES.UNITS
however,the building ori emrntia Bold w, in oneyemorcompletion,theowner- TOT L:
builder will have r en of pmving that he d not 'mpeove fr purpose of
ala). TY. PLUMBING PERMIT
❑ wnprject See 7Y4am exclusive tufasnnor li" wntr totem, Q FLOOD ZONE' APN
a the project(Sec.)IUD,Business ted holamIll Cede:)th Cnntrxmr'e
Lime Lawdartathapply
.)Loan o rty, hobuilds.rim". I reon,o, PERMIT ISSUANCE
worn dram fm suchproj a n T(a)ll rnsd Punuanun the Co to,
Licca. Luca. ALTER-DRAIN&VENT.WATER(EAJ71
FEE SUMMARY
❑ I P C for Nis n BACK FLOW PROTECT.DEVICEL
SANTfARY y_N_
Ownc are DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
fPENSATION U' RATIO DRAINS
SCHOOLTAX YN__
❑ ereom,,enmm v t 'Trace of mxlf-insu of een am of RECEIPT#
e Q FIXTURES-PER TRAP
Work .'Comped nlnsur <rlk ani c o yNercof(S '.3 eb .)which ppgK FEE Y__N_
covers I c sunder sperm, RECEIPT#
Policy GAS .1 INCA OUTLETS
CoBUILDING DIV 51
mpany
❑ Cenifid copy i. ereby famished GAS-EA.SYSTEM-OVER4(EA
) PLANCHECK FEE
❑ Canifdcopyi.fill with me city inspection division. GREASPEANDOSTRI.WASTE INTERCEPTOR GRADING FTE
CERTIF ATEOFEXEMPTIONFROMWO 'RS' GREASETRAP
MPENSATION INSURANCE SOILS FEE
(Thissectionnadnot completdifthepmenitisfor a hundreddellars($1W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEEorlans.
1 if matin Neperfo cc of the work f hi thupe sissud,IshW WATER HEATER W/VENT/MECTR
not ploy.ny in my s as t to the Workers' PAID
Z mpens.tion f ifo mete WATER SYSTESU RE.ATING De Receipt N
0 Appli
z NOTI 'TO PU :If, r i e iii"n of Exemption,you should NEW RESIDENTIAL PLMB. SO.FT.
14 OTAL:
F > becawith comply
y sucorkh
.ions or this PerProvmit
af,a 4bor Cda you must
� , forthwith comply wird such o stuns or this permit Mall be dared revoked. BUILDJO F
4q I
0.Wi Q CONSTRUCTION LENDING AGENCY S EE
7 z I hacbY affirm Ort Be.isa mnswctom lending eg,ay for the pefavnenceof
V Ome work for which this permit is issued(Sec.3097,Civ.C.) L: r— I ^�
Lenders Name
Q W U Lender.Address QTY. MECHANICAL PERMIT FEE PLUMBIY6 FEE r—
I cer ify that I have rad mil application and ante that me above Information is
correct.I agree to comply with all city and county ordinances and nate laws refuting to \ PERMIT ISSUANCE MECH ICAL FEE
buRdingcmn ctionendhembyaumoriurepresenndvuof Wscitymennrupon Ne CON UCf10N TAX
V 2 alrovementioned property for inspection purposes. ALTER OR ADDTO MECII.
G7 (we)agrs to save,indemnify and kap es me City of Cupeorim against
lutbilities,judgments,cornradex,rosaihich ayi yµ agulnstsaid City AIR HANDLING UNIT(TO 10,"CFM)
in consequence egrantingofmis
AIR HANDLING,UNIT(OVER IB.000 CFM)
S- tare App,' Von to Date ` EXHAUSTHOOD(W/DUCI)
D
HA RDOUS MATCRIAIS DISCLOSURD• HEATING UNIT(TO 100,000 BTU) Dune Re eipt#
Will the ep0lic or future building mcupant shore or handle hvardous material
m defind by me Cupertino Municipal Cede,Chapter 9.12,and me Health end Safety HEATING UNIT(OVER 10),000 BTU) 2
Code,Serino 25532(a)T
❑Yes ❑No VENTILATION PAN(SINGLE RHSID)
ROLLER-COMP(3HP OR 100'"BTU) IS ANCE DATE
Will lair coma manta "building by he
nBay A.Air Quality
as Madam,annch ot qt
hartrict? air contaminants us defined by the Bay Area Air Quality Mrnngemem BOILER-COMP(OVER 100,IgO BTU) 1_a4 1
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.PT. AA#
maz
I have ad the hazardous..,crisis requiremems under Chapter 6.95 of me ^ //��
California Health&Safety Code,Sedan."25505,25533 and 25530.1 undersand Net
if the building des,,not currently have n tenant,that it is my ,respodsibifity family the /r(//'
occupant of me requirements which most be met prim m i...of a Certitude of LUN
Occupancy. /
Owner or authorized agent Dole L: ISSUEDBY:
OFF