27359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINON •-F7:FC'LKICAL PERMirNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION - BUILDING PROJECTIDF.NTIF'ICAI'ION 27359
BUILDING ADDRESS: 1 / SANITARY NO. APPLICATION SUBMITTAL DATE
lqtqlI W LOT# Z r
OW
ERS NAME: rl� _Pg0-NF.L C RACIOR'SME: LIC NO:
KI
�`/Aq/JC �JL . N/C - CONTROL#
rAR TF,Cf/FN YEE ' C I? B AD ESS: ❑
CONI' ET#L� PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
GN 510 ZU- 1102 PERMIT ISSUANCE BLDG ELECT- PLUMB
LICENSEDCONfRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I�lTli JO
WOOp 6;Z Thereby affitinflm,LICENSEDiCONTRACrprovisDECL RATION commencing with
6100_ Section7000)of Division Sof the Business and Professions Ced, it my license is in PANELS or
yfull once and effect. �laa
FZ� License Class Lia.# UPT020DAMPS 4 `
ceQ m Date Comma tor 201-IOW AMPS
F y Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Z O rn— OVER 1000 AMPS
I understand my plans shall pentad.public records.
OG—❑
SIGNS ELECTRICAL
Q Y x J Licensed Professional
�Ouwu11Q OWNER-BUIIAERmDECLARATION SPECIAL CIRCUIT/MISC.
m'O yan I hereby reason.irm(Se that I am exempt from the Gssions Cn e:Any
yc Law for the
W3ay which requirermit to 7031.5,Business and Professions Code:Anycity or county TEMP.METER OR POLE INST.
E'ce which requires a permit m construct,cher,improve,demolish,or repair any structure
s�}1; prior to its issuance.also requires the applicant forsuch permit to file a signed statement POWER DEVICES
K C O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aX0ce 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
tL or that he is exempt thuefrom and the basis for the alleged exemption.An violation of T
m_w p g pion.Any OUTLETS-SWITCHES-FIXTURES V �� /y�/kr
1_Z¢ Section 7031.5 by any application for uryrmit s.bjats the upplia.t1.a civil penalty of �'�JI/
KHpnot mtmthan five hundred dollars($5001). NEW RESIDENTIALELECIR SQ.FT. STORIES TYPE CONS'IRUCIION
❑ Lesowneroftheproperry.ormyemployeeswith wagesasthcirsolecompareation,
will Jobe work,andthc,amemrc is no,innndedmidfered forside(Sce.J(kW,Business
and Professions Code:'rhe Contractor's License Low docs not apply to an owner of
property who builds or improves perste,and who docs such work himself or through his
employ«s,provided thmsuchimprovementsarc not hiandedorofferadforsale.If. OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearafcomplction,the owner-
builder will have the burden of proving that he did not build of improve for purpose of
sale.).
❑ Las mencrofthe proper.am exclusively contracting with licensed contractors to QTY. PLUMD GPERMIT FEE FLOOD ZONE. AI'N
coaswa,be project(S«.7W4,Business and Professions Codc:)The Contmaorx
License Lawd«s not applytoan ownerofpropenywho builds n improves thereon.and P MIT ISS NCE
who contracts fn such projects with acommatods)licensed pursuant to the Contractor's
License La, AL'ILR-DR VENT- TLR(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this naso BACK FLO ECf.D VICIi UTSIDE FEES
SANITARY Y N
Owner - Dam RECEIPT#
DRAIN - R,R t CON
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihemby affirm thetlhaveacertifica¢o'consemmulf-ins ,Orn certifcute of 1 FIXT S PER TR P �+l RF.CF.IPT#
Workerv'Compensmion Insurance or a certified copy thereof(5 .380(1,Lab C.)which ` PARK FEE Y N
coversall employee's under this permit. RECIi f p
Policy# - GA -E YSTIiM IN 40UTLETS
HU1JWNG DI SIGN RES
Company EA.S S - VER4(EA) PLANCHECK
❑ Certified copy is hereby fumishmd. CA
❑ CeniliW copy is fled with the city i:,�division. IWA
SEpNU R WAS"fE INTERCE R GRA0INC
CERTIFICATE OF L%EMM WORKERS ETRAP SOIL$ rECOMPENSATINCE(This udionnaJnm be complemJis rorato Hundred da ($I W) R-SANITARY-ST G.2WFf. LNk E
or less.)
hich pis permit is issued, shallR HEATER ENT/ELECnot employ any person in any meanercome subject m the Wo PAID
Cnnpcnsation lzws of Celifomia. Data ,RS EM/IREATING Dte ReceiplN
Oz APPlicant
z O NOI'ICE'10 APPLICANT:If.after making this Certificate of Exemption,you should NE ESIDENTIAL PLMB. SQ.Fr. TOTAL:
r la, become subject to the Worker's Compensation provisions ofthe Labor Code,you most
fonnwith comply with such provisions or this permit shall be domed revoked. BUILDING F E
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FE
z 1 hereby affirm that there is a construaien lending agency for the peommunce of
U O the work for which thin Penna ix issued(Sec.3097,Civ.O.) )" ` ELECTRIC O
Lcndcla Name
1<nJcrs Address QTY. MECHANICAL PERMIT FEE PLUMBING F,
O U I certify that I have mad this application and state Out the above irdovnalon is MECIIANICA RE
correct. I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE.
building commuction.and hereby authorize representatives of,biscity m enter upon the
71
V z CONSTRUCT N'fAX
atwv(We) oreJm save. forinspection purposes. ACfEk OR ADD TO MECH.
(We) ream save,indemnify and keep Harmless the City of Cupcni against
liabilities,judgmrnrs.cos¢andesandexpenses which may in any way accrue againstt said
aid City AIR HANDLING UNIT(TO 10,0010 CFM)
in couseque ce of the grajowo� 't.
2 � AIR HANDLING UNIT(OVER 10,000 CFM)
ig entre cenOCommcm I Date EXHAUSTHOODCW/DUC's PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CTO 100.000 B'fU) Date Beato
Will the applicant or furore builJingoccupant stare or Handle hazardous material HEATING UNIT(OVER IW.fN10 B'1 U) TOTAL'.
as defined by the Cupcninn Municipal Code,Chapter 9.12,and the Ilcalth and Safety ;
Code,Section 25532(o)'1 VENTILATION FAN(SINGLE RFSID) IF
I591
❑Yes ❑No
�, E
(tT
Will the applicantor future builJing«cupam usecquipmentur Devices which emit BOILER-COMPOHPOR Hay"BTU) (�
mrdtas air contaminants as defined by the Buy Area Air Quality Management BOILERCOMP(OVER 100.000 BTU) Pica
istrial a/r
❑Yes El No NEW RESIDENTIAL MECH.—SQ.FT. e '0($5
1 bode read pe Hazardous materials reqimmmde
ues under Chapter 6.95 of the la F vJ
Califomia I lealth&Safety Code,Sections 25505,25533 and 25534. 1 mmerstanJ thm ,d�
robe handing docs tan curcndy Hove n tcnnnt,Ik t it is my msponsihiliry to nosily the �l/IV
occupant of the re,mor norms which mus,be at prix to issuance of a Campeau,of
Occupancy.
Owner or authorized ug In, Date O ISSUED BY:
OFFICE—