27829 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO . "13-EC" PERMIT No
27829
APPLICATION/PERMIT PLUMB ING-MECHANICAL
BUILDING DIVISIONIIUII.DING PRGJEI.'T IDF.NI'IF'ICATION
BUILDINGADDDRESS: �//� Y SANITARY NO. APPLICATIONSUBMITTALDATE
036 LA- Por76 �iho UNITM la -461.OTp
O iR NA�v� PHONE CONTRA Ib 'S NAME: NIC CUNI'ROI.k ✓✓✓VVV
oTiDn O)l 98s'� cubeb
•ARCHITECUENGINEER: LIC O: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/J epap �yN BLDG EL PL MECH
Oil.-l.� �/V er PERMIT ISSUANCE
LICENSED C NTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
004z Ihembyaffirmmat l a mlicenxdunderpmvisionsofChapter9(commencingwiN
POO Section70JfdMDivis1on 3ofthe Business and Pmfessiom Code,and my license is in PANELS
K Z W full farce lad effect. F g�
FZpy License Class.Lic.g UP 10200 AMPS //✓l
.�6y Dam Cunwcsr 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z ❑ 1 understand my plans shall be used as public..Ms. - Z //O
/D
C� SIGNS ELECTRICAL
Qy Licensed Professional
E'p < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0px-O'U 1 hereby affirm that I am exempt tram the Contractor's License Law forms
: following following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. Qp'�
m which requires a permit to construct,alter,improve,demolish,or repair any structure J7
;!I>� prior to its issuance,ava requires the applicant for such permit o file a signed statement POWER DEVICES
that he is licensed putsuanno the provisions of the CmInocur's License Law(Chapter
o. e�' 9(commencing with Section 7000)ofDivision 3 ofthe Business and Professions Code) SWIMMINGPOOLELECTRIC VALUATION
Ma, raffia he is exempt momentum and the breis for the alleged exemption.Any violadnn of / ry�
F.. �� �-
ZQ Section 7031.5 by any applicant for a permitsuhjecutheapplicantmncivilPenaltyof OUTLET'S-SWITCHES-FIXTURES 77
G not mom than five hundred dollua(5500). NEW RESIDENTIAL ELECTR S .FT
C o ❑ I,mownerofthepropeay,ormyemployaswith wages astheirsolecomen
psatlon, Q aFUNIPS TYPECONSTRUCTION
will do the work,and the structure isnot mandedoroffered for sale(Sec. Business
and Professions Code:The Commetofs License Law does not apply w an owner of
pmpenywhobuildaorimprovesthereon.nd whodoes such workhimselforthrough his OCC GROUP RPS.UNITS
own employees,provided Ibat such improvements are not intended or oHerad hostile.If,
however,the building orimprovement is sold wiflumbr,yearn completion,Ne owner- TOTAL:
builder will have the harden of proving that he did not build or improve fm purpose of 701
vide.).
❑ I,asowneroftheproNny,amexelusivelyconuactingwiNliceasedeonwctorato QTY. PLUMBING PERMIT IE FLOOD ZONE APN
construct the project(Sec.7(A4,Business and Professions Cade:)The Con actor's PERMIT ISSUANCE
License,Lawdoes not only to ua owner wproperty who builds or imprnvex thereon,add IF
who contracts fowelft projects with.ommiencow licensed pursu.towthe Conuacmrs ALTER License L. FEE SUMMARY
Cl 1 em exempt undtt Sec. ,B&P C Ibr this reason BACK FLOW PROTECT.DEVICE 5 NITARY Y FEES
N
Owner Dam RECEIPTN
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCHOOLTAX Y N
[II hereby affirm that l have acertfiewe ancone,to self-insure,cracenificnte of RECEIPTM
Workers'Cam FIXTURES-PER TRAP
Fensatian lnmmnce Ora certified copy Nertof(5<c.3800,Leb CJ which PARK FEE Y N
cnvers all employees ondenhis permit. GAS-M.SYSTEM-1 INC. OUTLETS RECEIPT M
Policy g BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished. 670 ,
❑ Cenifed copy is filed wise me city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This senior ncedambe completed ifthe permit is forms hundreddo11ers(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lei
I certify Bad int he perfnmmea of the work far whichthis permit is issued,l shall WATER HEATER W/VENDELECTR
not employ any person in any manner so as m become subject to the Women' PAID
,z Compensatian Lawsof Celifomia Date WATER SYSTEM/TRFATING Data Receiptp
APPlicam
z0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB SQ.FT. TOTAL
tli7i became subject to the Workels Compemsdwt provisions of the Labor Code.you must
aw forthwith comply with such provisions w this permit shall be clamed invoked. BUILDING ME nf}
CONSTRUCTION LENDING AGENCY SEISMIC FEB ✓✓uuIL7.
z I hereby affirm that them is a construction lending agency for the perfannana of
V O the wink for which this Permit is issued(Sec.3091,Civ.CJ TOTAL: � -O ELECTRIC FEE 7 a (0-T—
OP Name
P Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 7
U 1 cenily that 1 have read this application and stns thanthe above information is W
runner.ImpeetocamplywithalleiryarW cnunry ordinances and state laws relating to PERMIT ISSUANCE MECIIANICALFIM
buildingconsruction,and hes,rawhirire rtprearrudivesaffl is city to enter upon the CONST10N TAX 5Yl'
V z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH. gs31
V
(We)agree to save,indemnify and kap harmless the City of Cupertino spairet
Iiabilities,judgmenmcosta Orad
,cosex,samama
which y in any way wandragainst said City AIR HANDLING UNIT(TO 10,000 CFM) r
to �
fm grunting or this permit e
AIR HANDLING UNIT(OVER 10.000 CFM)
cunsegyee o(„Ie.M1Ja.tiL,i—
�✓altarree of Applicant/Commcmr a)ITm EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receiptp
Will the applicant w future building occupant store or handle hazardous material HEATING UNIT(OVER IW,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety M
0Yes El No J Qs
Code,Section 25S32(a)Y VENTILATION PAN(SINGLE RESID) '9.
ISSUANCE DATE
Will air cormandtorfuws defintnl by me
nBay Amex Air Quality Management
BOILER-COMP(3HPOR IfNI,(g10 BTU) P A 0
• hadurel? air contaminants as Jcfned by me Bey Area Air Quality Management BOILER-COMP(OVER IW,000 BTU)
Dismicf!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. IW
st a� as
1 have read the harandous materials requirements under Chapter 6.95 of the IWAR 9 1995
California I lealth&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a rmsmt,that it is my responsibility to notify the 0
occupant of the requirements which must be met prior to issuance of a Certificate of (Jr LUI'tFl aJ
Occupancy.
Owner w authwiud age, Data TOTAL: ISSUED BY:
OFF