27306 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
(,,TTY OF CUPERTINO ILUI O-L,i,.1 RI AL PF:RMITNO.
NG
BUILDING DIVISION APPLICATION/PERMIT PIA ROJ -MECHANICAL 27306
BUILDING IRPROJF.(;'1'IDENTIFICATION
BUILDING ADDRESS:
/ 1I 1//-�`)f'� SANITARY NO. APPLICATONSUBMITTALDAT1:
S �/' 1 I NIT# LOT# J�
S NAME.: PITOA R'S NAM L C NO I
O N/C COM'ROLN
URCHI'TECT/F.N EER: LIC NO: AppI1 S _,:!2 ❑
%
tCONI'ACT: PHONE: BUILDING PER INFO
QTY. ELECTRIC PERMIT FEE
BLDG PLUMB MECII
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
0Wz Iherebyaffirm Nat l am licenudanderprovixons ofChVtcr9(commencing with IOH O[SCRIPTION
W 00 Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
aWF fall forecznd of
F7ul Liccna, - s - Oy� Lic.p O UP 70200 AMI?5
F=y Data Contractor 201-1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
GOyK ARCIIITF.CTS DE ATION OVER 1000 AMPS
O! O 1 undersand my plans serol h,used as public records.
F,to F W SIGNS ELECTRICAL
Q Y�:1 Licensed Professional
C
ed< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOyO 1 hereby from that I am exempt from the Contractors License Law for the
tp�iay fallowing reason,(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLL INST.
_Fa 0Q which requires a permit to condroct,alter,improve,demolish,or repair any structure
,ocWts or to its issuance,allore res the applicant for such uo file a signed settlement
POWER DEVICES
prior 9ui pp permi gn
�K Q 0 that he is licensed pursuant o the provisions of the Contactor'a License Law(Chapter SWIMMING POOL.ELECTRIC
aaou' 9(commencing with Section 7000)of Division 3 offer,Business and Professions Code) SVALUATION
w=a or our he,,exem therefrom trod the basis for the aIle dexem t An violation f
rn p ge pion. ymoatona OUTLETS-SWITCHES-FI%TURES
FZQ Section den lm wryapplicant for S500). suhjecs Ne applicant Toa civil Penalty of
ESO not m1, to%nfivftheprcddollormyempl NEW RESIDFNDALELECIR _SQ.FT.
tYF� ❑ I,asowner0fthc property,ormyemployttswiN wagaavMirsolccompcnsation. STORIES TYPE CONSTRUCTION
q3� will do the work,and the samenum isnot intended or offered for sale(Sec. Business
and Professions Code:The Contractor's License Use does not apply to an owner of
pmpcny who builds m improves thereon,and who does such work himself onhrough his
owncreplayced Nm, s
s,provideat such improvena em intendedoroffendl forsale.If. OCC.GROUP RES.UNITS
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
❑ Las owner offhe property.amns
exclusively contracting with liceedcontra ,.ctorsFLOOD ZONE APN
consumer the project(Sec.7814.Business said Professions Cale:)The Contractor's -
LlcenseLawdoesnot apply to an owner0fproperty whobuildsorimprove,thereon,gold PERMIT ISSUANCE
who commas forxnch projects with acommmag)licensed purs min to the Centramors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt underSa. .B&P C for this reason BACK FLOW PROTECT.DEVICE. OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOft,ROOF,AREA,COND.
W(IRKMAN COMPENle ofem DECLARATION SCHOOL I'A% Y N
�1 Thereby affirm fhmlhave
noid a,ificateexi copy duoedf(Se 3800.m,or Lab C.)at,ofwhich FIXTURES-PER TRAP RECEIPT#
case. GAS
lnsumnce oracrniBM copy Nercof(Se<.3g00.labCJ which PARK FEE - Y N
col cy ell etanbyeG'cwder`tbiapasaefa GAg EA.SYSTEM-[INC.40UTLETS RF,IVISIOa
IVV TI lJr]� BUILDING DIVISION FEES
Company I GAS-EA.SYSTEM OVER 4(CA) PLANCHECK FEE
❑ Cenified copy is hereby fumished.
CenifiW copy is Bled withehe city inspection division GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATEOF E%EMPI'ION FROM WORKERS' GREASE TRAP SOILS FEB.
COMPENSATION INSURANCE
(This section need not he complecedifthe permit is forces,hundred dollow(5100) SEWER-SANITARY-STORM EA.2001T. ENFAGY FEE
or less.)
I cenify that in the performance of the walk far which this permit is issued,l shall WATER HEATER W/VEISTRiLECIR \
not employ any person in any n as to bacome subject to the Worker PAID
Compensation Laws of California abate vn WATER SYSTEM/BEATING Date Rmeiptit -
zz Appliesm
C NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workers Compensation pownione wf the Labs,Code,you most
5t forthwith comply with such pro visions or this permL shall be decmcdrevokcd BUILDING FE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U1 hereby an that them is a connmmline ion lending agency far e performance of O the wf6rork for which Nie permit is issued(See.3097,Civ.C.) 'TOTAL: ELECTRIC FEE
Lender.,Name
G" F Lenders Address Q'TY. MECHANICAL PERMIT FEE PLUMBING FEE
L.1 1 certify that 1 have read this application and sate that the above information is MECHANICAL FEE
>" 0. correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
re" buildo,ronormaicn,wdhemhyanhorre repoessamovesuf Nis city,.enmruponthc CONSIRUC TION TAX
U Z above-mentioned property for inspection purposes. AUTER OR ADD TO MECI I.
(We)ague no save,indemnify and keep h,roles,the City of Cupertino almost
liabilitia,judgmens,costs and expenses which may in any way accme against said City ALR HANDLING UNIT(TO 10.0111 CFM)
Ina « e (fere grantiagofth,permit.
BAIR HANDLING UNIT(OVER 10,000 CFM)
VaiS m of Appliean4Comracor as EXHAUST HOOD(W/DUCT) PAID
IIA%ARDOUS MATERIAL DISCLOSUR HEATING UNIT(TO 100,000 BTU) , O Date Rtteipt#
Will the applicant or future building occupant store or handle haxardous material l
re,defined by The Corcoran Municipal Calc.Chains,9.12,and the Health and Safety BEATING ON]'I'(OVER 100,000 BTU)
Code,gallon 25532(a)P VENTILATION PAN(SINGLE RPSID)
❑Yes ❑No
Will the applieunt or fulurc bui Iding acupam use equipment or devices which emit
BOILER-COMP(3HPOR 100,000BTU) `ISS [�CB DAT
head micas air comaminans as defined by the Bay Area Air Quality Maragemem BOILER-COMP(OVER 101.000 BTU)
District? AUG 141995
❑Y. ❑No NEW RESIDP.Mr1AL NECfI. SQ.FT.
1 have read the hvalloes materials requirements under Chapter 6.95 of the CfIY ser GurEH f INS
California Health R 2.5
Safety Code,Sections 25505.25533 and 534.I undersand Nat
if the building does not currently bave a tenant,that it is my responsibility to notify the
meaning of Ne requirements which must be met prim to isame ce of a Cerificm,of
Ocatpunoy.
Owner or autbomcd a gent Dae TOTAL: ISSUED BY:
OFFICE