27109 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO •- PERMIT NO. O
APPLICATION/PERMIT PLUMBING..MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDPY'1'IFICA'I']ON
LDINO ADORES 5: '- SANITARYNO. APPLICATION SUBMITTAL DATE
73/ /J /v,A UNIT# LOT# la
VNERS NAME ���}YAs'E: C TR OR'S NAME: LI NO: NIC 'O ROL#
v e4L� 8 Z4z, 1 J1�`A'nIT04 �./ets
ARC]111 LIC NO. RFo D 7• PFe S/ ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
D [;FiCf_ "A MECH
PERMIT ISSUANCE � Y_Av ❑
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RESIDENTIAL TOB DESC 10N-
nrdZ Ihereby affirmthat l am licensed underprovisions of Chapter9(commencimgwith
WOO Section 700 of Division 3 of the Business and Professions Code.and my license is in PANELS '
C V w Loll force and effect. ���
QZW License Class LiC.N UP T0200AMP5
vFi Q 4 Date ontraetor 201-1000 AMPS
FyZ ARC TF.CTS DECLARATION
ZOm— OVER IOOOAMPS SQ.1 kAREA $IS .FT.
O z_n 1 and my plans all be used as public records.
I..,yFW r SIGNS ELECTRICAL
Liccn Profession
OWNER-BUIIABRmDECLARATION SPECIAL CIRCUIT/MISC. Q�
XOd V 1 hereby affirm that 1 am exempt from the Contractors License Lew for th< \
W'Y W y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
Q which requires a permit to construct,alter,improve,demolish,or repair any structure
pourto its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES
W C p that he is hemmed pursuant o the provisions of the Contractor's License Lew(Chapter -
44�LL 9(mmmencing with Semicon]BOB)mf Divisimn3ofthe Business and Rofcssiom Code) SWIMMING POOL ELECTRIC V UATION
Wim or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
I—Za Section]03LShyanyapplicantforatit
pcmsubjcn annpc
stheapplicoacivilnaltyof
cc=n nm m1, townfivehundmddollarmyem). NEW RFSIDENTIALELECTR SQ.FT. STORIES; TYPECONSTRUCIION
C F_o ❑ 1,asowncrofthepropeny,ormyemployees with wagesastheirsokcompensation,
a3� will dome work,and the structure is not intended m Offered forsale(Sec.9(ki Business
and Professions Code:The Contractor's License Law does nut apply to an owner of
propenywhobuildsorimpowes thereon,and whodeessuch work himselfor through his
employees.Provided thatsuch improvemmur,
ese not imendedoroffered forsale.If.
OCC GROUP RES.UNITS
however,the buildingor improvement is sold within one year ofecmpletion,the owner- T �"
budder will M1ave the burden of proving that he did not build nr improve for purpose of
o
feI,
❑ QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cas wneroflhepropeny,act exclusively contracting with littmedconvnnors m
Grove,the project(Sec.7(s44,Business and Professions Code:)The Contractor's
License Law aces not apply man ownermpropeny who buildsor improves thereon,and
PERMIT ISSUANCE
who conwets for such pmjects with a contractor(s)licensed pursuant m the Contractor's
License Law. ALTER-DRAW&VENT-WATER GIA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE - OUTSIDE FEES
SANITARY Y N
tX)
Owner Date RECIi1FT p
DRAWS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
(� ❑ IherMyaffirtn that lhave acertificate of consem to setf-insure,ore certificate of FIXTURES.PER TRAP RECEIPT
Workers Compensation Insurance nr a certified copy themof(Sce.380 ,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECHIPT
Policy#
BUILDING DIVISK FENS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ZI
❑ Ccnifisdemlyishmebyfrmiabcd.
❑ Cerified copy is fled with th<cily inspection division. GREASFJINDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nm ba completed{fthe permit is forces,hundred dollars($100) SEWER-SANITARY-STORM EA.2WIT1', ENERGY I'
or less.)
I certify that in the perfmmmnce of the work for which this pctrnit is issued,I shall WATER HEATER W/VFNT/ELECTR
not employ any person in any manner so as to become subject to the Workers PAID
WAR SYSI' TREATNG _41 Recept#
Z Compensation LawsofCalifomin. Date Dtv
Applicant
0 NOTICETO APPLICANT.If.after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. ESQ.ET. TOTAL:
^fir becomesubj«uo the Workers Compensation pmvisions nfthe Labor Code,you must
a ,.
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE �+
fS] SEISMIC FEE
4 Q CONSTRUCTION LENDING AGENCY
Uz I herehy affirm that is a construction lending agency for the performance of ELECTRIC FF.E
0 (he work for which this permit is i.ssued(Sce.3099,Civ.CJ l
Lender's Name
C) F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FE
0 U 1 verify that 1 have mad this applicmion and nate that the above information is MECHANICAL F-E
r�" W correct.Ingres,to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
(•" buildingeonstruction,and hereby authorize representatives Alibis city tocnrerupon the CONSTRUCTION AS
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)ngrce to indemnify and keep harmless me City of C.,di.against
fatal...c,,jud m ito tpsom,which may in any way no,meagairemmed City AIR HANDLING UNIT(101 hih)CFM)
in copse y the gr g of this permit.
AIR HANDLING UNIT(OVER IQIXq CFM)
i<�-✓e t�
ureof Ap mast/Contractor •Dates EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ilk,"BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hvardous material
as defined by the Caprino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,M BTU) TOTAL:
Code,$,.,an 25532(ml VENTILATION FAN(SINCLH RHSID)
❑Yes ❑No ISSUANCE NkXE
Willthca licant nr fuwrebuildin fusee tnrdevices whichemit BOILER-COME 3HP OR EXLM BTU)
pp g«capon gmpmen
haus zardoair contmninants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0N)B'TU)
•
Disnot
❑yes ❑No NEWRESIDENTIAL MECH. SQ.IT.
1 have read the hazardous materials mviumnar,under Chapter 6.95 of the 0
California l Icalth&Safay Cede,Sections 25505,25533 and 25534.1 understand that
if the building does not currendy M1ave a meant.that it is my mspmnsibility to notify the T
occupant of the tequiremems which must be met prior to issuance of a Certificate of ®�• '
Oreupancy.
Ownerorembarimdagem Date TOTAL: ISSUED 13'1.1n tit a. t✓
OFFICE