27837 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 7)IN(i-ELLUrRICAL PERMIT NO. 8
APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION 37
BUILDING PROSKCT I3I551ACA-1'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
9 6 VI Q. P., s 0 s UNIT /Q LOT# 1,3
�/� �L
OWryLµ/N1ciafc" H PHONE:02"CIS qe^_4(� CONTRACTORO A�,n�h LIC NO: N/C CONDUL# J
ARCCHI'FECI'ANGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
L4 p.pA2 e r Q 6/ PERMIT ISSUANCE BLDG ELECT PLUMB MEC
t�
LICENSED C NTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
KZ Ihercby affirmision 3 ofth Business and
Code and mmecense wish
ix00C fall fore saidnfect.Division Business and Professions Code,and mylicenseie in PANELS
K U U full force and effect. �� I
cei License Class Contractor_
UP T0200 AMPS F/+
lazy Date Contruotor 201.1000 AMPS
F'vi Z ARCHITECTS DECLARATION SQ.IT.FLOOR AREA S/SQ.FT.
Z O_y—^ I understand my plans Mall be used a public records. OVER ItIW AMPS ^
QY � Licensed Profcasionul SIGNS ELECTRICAL
Cy.W6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
{a�5Oa1V, 1 hereby affirm that 1 not enempifrom Ne Contractor's License Law for the
u+�0rQn following mosoo.(Sectan]031.5,business end Professions Code:Any city or county TEMP.METER OR POLE INST.
rn J which rtquirts a permit to constrvct,elRr.improve,demolish,or mpeir shy armcru
p}$ hothe s fic...exipamarmt th thrclisicantfla.Com ase.,aLiesm geed statement POWER DEVICES
p that he is licensed pursuant m the provisions of the Comment's Licenu Law(Chapter
6KeQ�d 9(commencing with
therefrom
and
Division 3oftleed Business add,AnyvilaCode) SWIMMING POOL ELECTRIC VALUATION
or that he trf Section
themfmmund the basis mfonjets theAenemant 1.Anyviolmian of OUTLETS-SWITCHES-FIXTURES �
F Z G Station than
n by any dyed dint fora 00). subjects the applicant m a civil porosity of 7 �i (/ .
�= not sort than foe hundred dollars(E500). NEW RESIDENTIALELECTR 5 .FT.
KFS ❑do
wrk.andepropeny,m myemployeal wisM1wugcsasthei(Soo.compeosinen, Q STORIES TYPF,CONSTRUCTION
a3— will Professions
and the he Communes
Law
dos net apply in an owner
ss
of
and Prtywhi 1m Cade:The Oamrecrrs Littnse law does not apply If ri owner is
msmorn wycei.pdaorimproves chempirmi dwho does suchwork himulfor throughhir
ml tts,p ori improvement
OCG GROUP RES.UNITS
c poy provemenuea not inundedorof(emffmaNe.If, i#ffsL
budder ,will have building
teburden
im of proving
i that he didme
build o improve for t purpose
f TOTAL:
builder will hove the burden of proving thus he JiA not build or improve for purpose of
sale.).
❑ I.asownerofthe property,ameaclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7054,Business and Professions Cade:)The Counselor's
License Law does not apply to an owner ofpmpeny who builds or improver thereon.and PERMIT ISSUANCE
whocontnas formch projcets wish.cantraam(al licensed pinommu me Contractors ALTER PEE SUMMARY
License Law. WATER(EA)
❑ I am exempt under Sm. ,B @ P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY YN
Owner Dale DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT0
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IhembyafrmthilhaveamniFicmeofconunuoulf-insus,oraanificaleafRECEIPTN
FIXTURES-PER TRAP
Woenalle ployes's nlnsunnceor rmit. 0ul copy themof(See.3800,Lab C.)which PARK FEE Y N
en all employ«a undo tits pcmhit GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT'#
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE O
El Certified copy is hereby famished.
❑ Certified copy is filM with the city inspection diviaior GREASFIINDUSTRLWASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplued Hits permit is forage hundred dollars($1010) SEWER-SANITARY-STORM EA.2KFT. ENERGY FEE
others.)
Icenifynhm into,pafomunceofmc,work for which this permit is issued,IMell WATER HEATER W/VENDELEM
not employ any person in any manner
s o as to become subject m the Workers' PAID
2 Compcnsmiontawsof GOifosia. DamWATER SYSTEM/IREATING Receipt#
Applicant a
rOr�yy D NOTICE TO APPLICANT:If.afar making this Certificate of Exemption,you should NEW RFSIDENDAL PLMIL SQ,FT. TOTAL:
t-^ V3 become subject no the Workers Compenutan pros.soon of Ne labor Cade,you must
tai > forthwith comply with such provisions or this pcmd shall he deemed revoked. "03 ME
y A CONSTRUCTION LENDING AGENCY SEI IC FEF t^D
I hercbyaff Nan them is a construction lending agency for due perf..of TOTAL: ELECI'Itl FF:E V
V O the work for which this permit is issued(Sec.3097,Civ.CJ X� / IDN Q S
Lender's Name
I'L' F Lender's Addms PLUMBIN FEE
U QTY. MECHANICAL PERMIT FEE / 70N
1 certify tot 1 have reed this application and rime that the shove information is MECHANIC FEE
7" 0. cording lagsenem.comply
and with all city and county ordinances said sea laws relating a PERMIT ISSUANCE Q��a•�Q
U Z abovengconmuctiomand hmbyauction vapasenutves ulNis cirymenur upon Ne CONSTRUC IO TAX N /
L) z above-mO agree
property for inspersion purposes. ALTER OR ADD TO MECII.
(We)agreeto,costindemnifyusedkeep myin sthe City of,aganst said Citt �k.� c ��
liabilitiu,judgmenu,corse and eapenuawhich mayinany way.,against said City AIR HANDLING UNIT(TO 10,000 CFM) ?./P/.
me.:aeque r
eofthegr 'ng of this Pet].I. /�
V AIR HANDLING UNIT(OVER 10,"CFM)
LL!
Si,ghme ofApplicam/Comtel., /r Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the the Cium or furore building occupant erre or and the
Health a material
in Code,Section
the Cupertino Municipd Code,Chapter 9.12,end the Hedth and Safety HEATING UNIT(OVER IW,(100 BTU) T09'Ay�L: n/'
Code,Scui❑Y932(a)] 11 No VENfILATTON FAN(SING LH RPSID) �rN p{ 7
BOILER-COW UHP OR 100,000 BTU) IID ] Fk DATE
lasWilltair co icannspits s building by thentuu AreaAen Quality
awagemeit APR y5
Distant? air comeininants nee Aefnnl by the I{ey Area Air Qmiiry Management BOILER-COW(OVER 100.1100 BTU)Disldcl2 EI Yes ❑No CITY ser GUr�n 1IrvU
NEW RESIDENTIAL.MECH. SQ.FT. , ,.,
I have mandeth Ne fV Co ,mdi.,s rcquiamems odder C.fur cost of the
Cilie building
do @ Safety Cade,Sections 2350;2SSii and 25534.1 responsibility
to notify
Net
iftheardo me
not currently have atenant,that it is to ssuvre iota i notify the
occupant of the ts9/trctrcnu wh'h must be met prior to issu <of a C�nifceu of
Occupancy. / s ��i{�� .
Own— /fbarnudagem Dau TOTAL: 70N ISSUED BY:
OFFIC