27211 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF�.•l)PERTINO UlLISING—F7}.LTRiCA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27211
BUILDING DIVISION BUII.DING PROJF.C'1'IDENTIFICATION
BUILDINGADDRES�S: I CL SANITARY NO. APPLICATIONSUBMHTAL DATE
-2 a a DNIT# Ian #3 LOT# y 22k-'gi'
LANE NA��++E: /`�, PI199,N, CONTRACTOR' NAME: LIC NO: N/C CONTROLN
a T%ON lTom Y OOD ��n e N
• ARCHITLCiENGINEER: LIC NO: ADDRESS. ❑
CONTACT: PHONE:
/ QTY. ELECTRIC PERMIT FEE BU
�O B �ILDING PER�MpIT(B M
INFO
ECH
gee li�� For PERMITISSUANCE
/ .CNJ ICJ ifE7
Of�D
LICENSE CONTRACTOR'S DECLARATION XAPPLIANCES-RESIDENTIAL TOB DESCRIPTION
C 2 I hereby affirm that l am licensed underpmvisions ofChapter9(commencing with 00 Section and of Division of the Business end Professions Cwle,end my is in PANELS ��
y.WUW full force lass effect.
fa„ZW I,ittnse ClassLic.p IIP T0200 AMPS
m G oi Date Cartoon 201-1000 AMPS
ARCHITECT"S DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Z8.'4 OVER 1000 AMPS
OZ—,Z 1 understand my plots shell be used as public records.
r 4 iqz'W
s. 3 S6
AN Liansul Pr.fcsicANnal SIGNS ELECTRICAL
a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
B' 1 hereby af0rm
9that I am exempt from the Contractor's License Law for the
W 3 m following reason.(Section 7031.5.Business and Professions Cade:Any city orcounty TEMP.METER OR POLE INST.
which requires a permit to construct.alteq improve.demolish,or repairan tana.dre
priori.its issuance,Wso myuites Neapplicantfar, such permit.file.signed.niument POWER DEVICES
,11K G Oz that he is licensed pursuant to the provisions of the Contractors License law(Chapter
PKC V. 9(commencing will,Section V000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W-.m orthal ion 7031.5 by my applicant
the Permit subjects
is the exlicant n.Any ivil penalty of OUTLETS-SWITCHES-FIXTURES as9# �—
Z} Section a than by any applicant(ora permit subjects the applicant m a civil penalty of
W G not are than rofive hepmrc rtty,ormyempl
❑ I,us.wnerafthepropeny,nrmyemploy«e withwegesnslheirsolec.mpensation, NEW RESIDENTIAL ELEGIR _SQ.FT. STORIES TYPE CONSTRUCT0N
y32o will do the work,and the stmnure isnot intended conflicted formle(Sec.7044,Business
and Professions Code:The Contractor's License law does not apply m an owner of
property who builds or improves thereon,and who does men work thimselfor through his OCC.GROUP RES.UNITS
own employees,provided that such improvements arc not intendedoroffcied for sale.If,
however,the buildingor improvement i&sold within one year ofcompletion,theowner- TOTAL:
builder will have the borders of proving that he did not build are improvery
for puou of
side.).
❑ Las ownernfthepropeny,amexclusively connecting with licensed contractors to QTY, PLUMBING PERMIT FEE 1.0 ZONIi APN
onstmct the project Sex.7044,Business and Professions Code:)The Convectors
Llcensel.aw tl«sow upplym la.wnerofpropeny who builds ofimpfovesthefeori PERMIT ISSUANCE
who contracts formch projxd withacomracimbid licensed pursuant m the Convectors
License law. ALTGR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Rate DRAINS-FLOOR,ROOF,AREA,COND. RECE1Pfis
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
•
covers l hereby affirm that l have a cenificane ofcansenrto self-insutn,me«rORcam of FIXTURES-PGR TRAP RECEIPT is
Worketx'Comnce a
pereltinn In afcenified mpythercof(Sec.3800,Lab C.)which PARKFEE Y N
rs all employee's under this pmmit. GAS-IA.SYSTEMA INC.4 OUTLETS RECEIPTM
Policy# BUILDING DIVISION FEES
Company
❑ Certified ropy is hereby famished. GAS-EA.SYSTEM-OVER 4(CA) PLANCHECK FEE
❑ Cenified copy is filed with the city inspection division. GREASR(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need now becompleted ifthe permit is forces,hundual dollars($1010) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icenify that in theperfnmrtmceofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Fenian in any rammer an as to become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSIEMIMEATING Date R.ipt#
Q Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLAN. SQ.FT. TOTAL:
F VJ became subject to the W«kces Compensation Provisions of the Labor Code,you mum
forthwith comply with such provisions of this permit shall 4 deemed revoked. BUILDING FEE r—
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE / a 7D
1 hereby affirm Nat there is a construction lending agency for the performance of
U O the work fnr which this permit is issued(Sec 3097,Civ,CJ TOTAL: ELECTRIC FEE J S
Iends,r.Name PLUMBING FEE
O F lenders Address QTY. MECHANICAL PERMIT FEEa
V 1 certify that I have read this application and state that the above information is 0. #coned.Ingrecmmmply with all city end«unty oNinances and state laws rclmingm PERMIT ISSUANCE MECHANICAL FF.E
y building construction,and hereby authutixe representatives of Nis city mender upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
G (We)agree to save,indemnify and kxp harmless the City of Capriole.against
liabilities,judgments,costs and expenseswhich may in my way accmeagainst said City AIR HANDLING UNIT ITG 10.000 CFM) CHs # 1.3-f5
in. of the granting a(this permit. AIR HANDLING UNIT(OVER 10,000 CFM)
1+..4 � i ���I �� EXHAUST HOOD Signnum.(AppliconVCmnm r Dale PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Receipt#
Will the applicant of future building occupant smrc or handle humorous no mrist
as defined by the Cupertino Municipal Cade Chapter 9.t2,and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(x)7
❑Ycs 1:1 No VENTILATION FAN(SINGLE RISID) �3
Will theeppliclatorfuwrt building«apanmseequipmenmrdevices whichemit
BOILER-COMP LHIP OR 100,000 BTU) ISSUANCE DATE
bnrallous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A D
•Disvicft
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the brimill us materials requirements under Chapter 6.95 of the H 1995
Califomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that ^
if the building does te
not currently have a nant,that it is my responsibility to notify thC'e
�VI
occupant of the myuiroments which must be met prior to issuance of o Certificate of f
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE