27852 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF
BUILDING APPLICATION/PERMIT PLUMBING
DI - XCHA I 1,
BUILDING PROJECT'UDNN'11FILATION PfiRMIT NO.
27852
BUILDING ADDRESS: SANITARY APPLICATIO4NSU_HMHTALDA9E
D LOT# /O ^� / ^ /Q1 oK{ /µ
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OWNE AM1 1 ,[(�( PII E: CONTRACTOR'S NAME: LIC N(L
-a//rOn /�OM(itS S 40 0Caneh N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEP. BUILDING PERMIT INFO
Www {.' BLDG ELECT PLUMB MECH
Tee- (ap �/' Dp 70-14"_
0 PERMIT ISSUANCE X X f[X
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb firm East l am licensed under l'Chnt 9(commencin LOA DESCRIPTION
F p02 ye prrvisifeso per eis in
t`�1 W00 In Iiaceandn(DivisinnJnf the Business and Pmfessiona Cale,and my license is in PANELS �1
W< V full fosse and eRaL G\J L
FZy{ Liernse Class Lie.p UP TO 200 AMPS
why DoleContractor 201-I"AMPS
I-onARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.Ff.
zOrn� OVER I"AMPS
O z_() I understand my plans shall be used as public records.
r L t of SIGNS ELECTRICAL. //0
6�d�� Licensed Professional
X pd d'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /
°�OyF 1 herebffir
y am thin xe
I um empt from the Contractors License Law for the ��
IfrJ/je
W 3 a m6 following reason.(Section 7031.5,Business and Profei siov Code:Any city or county TEMP.METER OR POLE INST.
�S=OJ which requires a permit to construct,alter,improve,demolish.or repair any structure
$d�Y� prior at its issuance,also remakes the applicant for such permit to file a signed statement POWER DEVICES
OO that he is licensed pummnt to the provishan of to Contractor's License Law(Chapter
9(commencing with Section]00))of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or f Sechat tion 7031.5 bywbertfromandthebarisforthetsthedexempttto civil Penalon ty
FIXTURES /9y 6d3 ,
> Sectioneisexerway applicant for e perricabasis subjects theexemmnoa civil pemlty of OUTLETS-SWITCHES-
G nm more than rive hundred dollars(S500).
❑ l,as eroftheproperty,ormyemploymswitwagesmthcirsolecompensation,
NEW RESIDIiNTIAI.ELECTR _SQ.FT. STORIES TYPECONSTRUCTION
a wiildotework,mdtesmsctumisnmimmdNoroffe foraale(Sm.]044-Business
and Professions CMe:The Contractors License Law does not apply m an owner of
property who builds or improves thereon,and whodonsuchwork himselfor through his
owitemployces,providedthatsuchimprovemmtswenotintendedoroffwcdformle.If. I OCCGROUP RLS.UNITS
however,the building or improvement is sold within oneyearo(completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose M
sale.).
❑ I,as owner of the property,amexclusively contracting with licensed contractors to QTY, PLUMBINGPERMIT FEE FLOODZONH APN
amstrmct the project(Sec.7014,Business and Professions Coded The Contractors
Licenss Lawdossnot apply manownerefpmperty,whobuildsorimprovesdammn,and PERMIT ISSUANCE
whocommen for such projects wit a contramood licensed pursuant to the Conumcrosrs
License Low. ALTER-DRAIN&VENT-WATER( FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far this reasonDI
BACK FLOW PROTECT.DEVICE OUTSIFEES
fARY Y N
Owner Date RECEIPT'q
DRAINS-FLOOR,ROOF,AREA.CONO.
WORKMAN COMPENSATION DECLARATION TOOL TAX YN
❑Workers'
affirmthaInsura a ora seterf copythereof(ec.380r#ate C.)which
RECEIPfN
FIXTURES-PER TRAP Work as'employeesnler this Permit.
ified copy thereof(Bac.38#0,Lech C.)which PARK IEE Y N
coven all employees under tis permit. RECEIPT Is GAS-EA.SYSTEM-I INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Compmy GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE .10
❑ Cenifted copy is hereby mousiest
❑ CertifiW copy is filed with the city inspection division GRFASIUINDUSTRL WASTE INTERCEPTOR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEL?
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars(5100) SEWER-SANITARY-STORM EA.200FT, ENCRGY FEE
to lees.)
I certify but in the performance of the work for which this permit is issued,Ishan WATER HEATER W/VF-NTIELECTR
not employ any person in any mummer so as to become subject to the Workers' PAID
z Compemationlawsof Califomia. Date WATER SYSTENVRIi TING pate ReceiptN
Applicont
z 0 NOTICE TO APPLICANT:If,after making this Cenifcme of Exemption.yam should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
P fn hccnmsubject e subjeco me Workerspe
Comnsation provision rids,labor Cade,you must y
Fes' ; forthwith Comply With re
Such previsions or tbe is permit shall deemed revokedFE
. BUILDING E Ogb`0�
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that hem is o construction lending agency for the atfamnnce of
U O the work for which this permit is Issued(Sec.31197,Civ.CJ TOTAL: ELECTRIC FEE A1.7.2
Lender's Name
wO V Let der',Address (Try. MECHANICAL PERMIT FEE PLUMBING PFR 16%
1 certify shot I have sad his application and stem that rhe above information is �� ��
1 correct. I agree to comply with all city and county ordinances and sale laws rclNng do PERMIT ISSUANCE MECHANICAL FEE s
_ huildingconstraction,and hereby authnriu represemativesofthis city to enter upon the CONSTRUCTION TAX
C) z ahirve-mentioned pm,oy for inspection puryoses. ALTERORADDTOMECII.
(We)agree m vee indemnify and keep harmless to City of Cupertino against u�#
ina]ihies,jud;i ,[rata andexpemeswhichnaya nay way accrueagainst said City AIR HANDLING UNITfTO 10,000CFM) ME7
in nms,yuenc the granting permit.
- AIR HANDLING UNIT(OVER 10,00)CFM)
Sigi col Applicata/Condructor Date EXHAUST HOOD(W/DUCId
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dme Receiptis
Winds,the Cu:mrtinoM iciial Code,Cantswm or handle Health and Sae,, II RATING UNIT(OVER IOE0110 BTU) TOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the 1{rash and Safety w
Code,Section 255]2(,)?
❑Yes 13 No VENTILATION PAN(SINGLE RESID) QVai
ISSUANCE D.
Willtheepplicmmrfmurebuilding occupantuseequipm<m ordeviceswhich emit BOILER-COMP(3HPOR IOO,OW BTU) s-v 1
• hazardous air contaminants as defined by the Boy Arco Air Quality Management BOILER-COMP(OVER 100,000 BTIO
°`"""' OCT 91995
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ,SQ.FT.
I have read the haaardaus materials requirements under Chapter 6.95 of tc CITY yr uurw ia'
Califomia I Iwlth&Safety Cale.Sections 25505.25533 and 25534. I understand tet
ante ti,fin res na cun,ntl havcatcraa,that it is my responsibility to notify the
occupant a equircm hick must be met' ar to issu of s mmlficate of
, /0 9
rvutorizcd agent Uate TOTAL: ISSUE BY:
OFFICE