27159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOINi1=ELLLI l A PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL eI C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 1 J
BUILDING ADDRESS: f� ` ,'/�J SANITARY NO. APPLICATION SUBMITTAL,DATE
-Ityl12. LARRY M11A 1 UNIT# LOTa
OW. SNAME: PHONE: C ACTOR'S NAME: LIC NO:
C US 52- RrEC'TIoSJ VW M I V I qqS "" °"R a
O ARCHITEC'DENGINEER: LIC NO: ADDRESS: El
CLART15SAJC', QO:RbE qs/
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTLUMB MECH
PERMIT ISSUANCE , 1:1 1:1 1:1LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
O=Z I hereby affimt that l am licemed underprovisionsofChapter9(commencing with JOB DESCRIPTION
�00F. Section 70)l Division 3 ofthe Business and Professions
�kCode,and my license is in PANELS
6« Lire,,fare, Lelf _ Lica (JOr UP TO 2M AMPS
v�i,60aiilwc Curnernr O UR 201-1000AMPS S FT.Fl.00 8/SQ.IT.
ZOvtns� ARCHITECTS DECLARATION OVER 1000 AMPS Q
oz-0 I umdersland my plans shall boused as public records.
P y F; SIGNS ELECTRICAL
Q Y ,� Licensed Professional /N
Y
❑'•S
OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC. 1vA`
KOaF I hereby affirm that 1 am exempt tractive Contractors License Law for the
W 3 W m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
,,0 which rcquims a permit m construct.cher,improve,demolish,or mid,any structure \
CD}M prior to its issuance,alsorequires the applicaotfor such permit to file a signed sutemmePOWER DEVICES
W IY n pthat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
p•XOK LL 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VA ATION
W_o, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES \
FZ' Section 7031.5 by any applicant for a Permit subjects the applicantto a civil Penalty of
FSO¢ not morcthun five
rofhe mf ny,ormyempl NEW RFSIDENTIALELECfR _SQ.FT. STORE' TYPECONSTRUCTION
� dollars(SNESL
F22 ❑ othe wrk.andepropeny,armyempbyeeswithwagesasidei(See 04L,Business .
a 3— will Pr fie work.0 d e The Cureisnormmn ease Law doeshad not apply to air Business
and Professions Cod,:The Contractor License Law does not apply lf an owner of
pnrperywho buildemimpnwesthereon vementts onoontend d6rofflforlhr.ugh his OC .GROUP RES.UNITS
ownempinyces,provided that such impmvemenlsarenolimendeJdroffered(orsdc.IL
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.)' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Las the profit(Sec. ny,am Business
and nvaaiio with dee)The Ctmctorsln
scene the Project apply
]IMA,Business anti Profproperty
build Code)The Contractors
License Law does not apply toawith acontractors)
nta tors)whased pursuant
int Inde Corea,and PERMIT ISSUANCE
whence Lsnsforsuch pmjectswilh aconvactoKs)licenud pursuanuothe Contractor's ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
' Licenselaw.
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UPSIDE FEES
SANITARY YN
Owner Dam DRAINS-FLOORROOFAREACOND. RECF;IPTp
, , , .
WORKMAN COMPLNSA'1'ION DECLARATION SCHOOL TAX VN
❑ Iherchy vffrm thatlhavc a<erifcam of canxenuoself-insurc,oracenificamof FIXTURESRECEIPTp
%TURES-PER TRAP
Workers'Compensationler this Permit.
fled copy thereoflSe<.3800.Lab C.)which PARK FEE Y N
onvers all employee's under permit. GAS-EA.SYSTEM-1 INOgOIITLFTSRp
DIVISION
Policy a BUILDING DIVISION FF.FS
Company GAS-EA.SYSTEM-OVER 0(EA) PLANCHECK FEE
❑ Cenifedcapyislmfcbyfumiehed.
❑ CenitieJ copy is fled with rhe city inspeniun Division. GREASFJINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is for one hundrtddollars(SIM) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE
or less.)
I ttnlfy that in the perfnrmaneeof Ne work for which this permit is inued.I shall WATER HEATER W/VENTJELECTR
not employ any Person in my immune
s o as to become subject to the Workers PAID
,z Compensation Lawsof California. DateWATER SYSTEM/IREATING Data Rescipta
Applicant
O � NOTICE 10 APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject o the Worker's Compensation provisions of fie Labor Code,you must
a > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDI NO FEE
ISI ` SEISMIC FEE
0. CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is a construction lending agency for Ne perfermvmca of
thWIT e work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
V O Lender's Name
C)
pLenders Address QTY. MECHANICAL PERMITPEE PLUMBING FEE /.
C) I certify that 1 have read this application and state that the above information is MECHANICAL ITH
correct.lugrte to comply with ell city and county oNinancesaM amm lases¢Irving to PERMIT ISSUANCE
F
buildir,emouu tme,and hereby authmiu rcprtxnmtives of thiscity toemerupon the to CONSTRUCTION TAX
VZ above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep hareadessthe Gupenagainst
lvhilitcs,judgmenrs,costs and expenses which may in any way accrue against said
City AIR HANDLING ON]'1'('1'O 10,000 CIM)
ce W the granting of this pemtit. I�
' AIR HANDLING UNI]'(OVER 10,000 CFM)
Signamr of ApplicanUContmchn am EXI IAUST NEED(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE ha dl
HEATING UNIT(TO 1110,1100 BTU) Dam Receipra
Will by the Caperton Municipal
al Code,Cantstoreor handle Hoath and Safety
ABA'T'ING UNIT(OVER 100.0008'N) 'r('I'AL
as define)by the Cupertino Municipal Coda Chapter 9.12,and be Hedth and Safety
Code.Section x)?
yes
❑Yn El No FNVTILATION FAN(SINGLE RFSID) I
ISSUANCE DATE
Will the applicantorfulare building occupant useequipmrrawdevices which wail BOILER-COME LIMP OR 100,000 ITU) I
hvardou.s air contaminants as defined by the Bay Area Air Quality Mamagernent l r.,
BOILER-COMP(OVER 100.000 B'TU7
District?
❑Yes 0 N N17W RESIDENTIALMECH. SQ.FT. o
1 have mad the hazardous materials requirements under Chapter 6.95 of theCalifCT 1319,9
14
iI the eia ing do s safety end,,Sections m%ma25533 and e,ximi 1 understand that
amebatld f,hc menmcuremly have as,hetthmit is myresplmsihilirymosaily the - " k.r
occupant of the reyuiremsms which must be and prior to issuance ofa Cenificarc of s'Vf•q.IsfJ
Occupancy. ._
Owner or anthorixed agent Date TOTAL: ISSUED B•Y
OFFICE