27995 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY t
CITY OF CUPERTINOn cojoin-P.I.PF."I'un. PERM]TNO.
APPLICATION/PERMIT PLUMBING-MECHANZ11. (�
BUILDING DIVISION HUILDINGPROJCC1 IDEN I'IFICATION J J
BUILDINGADDRESS: / - SANITARY NO. APPLICATION SUBMITTAL DDATH
AcvmV UNIT# 1.0'1'0 �f
OWNERAM PIIONE: CO R OR'S NAME: I LIC NO: N/C I CfONTR01.p •l
flO 2S - 8i o - O
ARCHITIf '/i GINE.K: LIC O: ADD ESS: h C ,Dv ❑
CONTACT: PHONE: ;t?ELECTRIC PERMITFGE BUILDING PERMIT INFO
t
2�'� PERMIT ISSUANCE BLDG ELECT UMB MF.CIi
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC ION
qzz, Ihereby affirm mmith
that l am licensed under proviaionsofaripter9(coencingw
+1 UZ,{'; Senior 7")of Division of the Business and / Code,and my license is in PANELSTO2 � � �`
FZW L'mlenxC�d effecC� /' Lic.M �� 7 / D UP T0200 AMPS
mDN Dam (� Common 201-1000 AMPS
ZCH,, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
oy_C l understand my plans shall be used.,public records.
SIGNS ELECTRICAL
q'� Licensed Professional
OWNER-BUILDER.DECLARATION 'SPEC AL IRCUIT/MISC.
I hereby nm ffrthat I em exempt liarm the the Contractors License Lew For the
413¢rn fNlowingrmxno Swelinn7101.5,Business and Professions Code:Any city or county
TEMP.METERO POI.&JOTS
of which requires it permit to construct.alter,improve,demolish,or repair any structure
KW� prior to its issuance,also requires the applicant for such permiito file a signed smmment POWER DEVICES
that he is licensed Pursuant o Ilia proviainus of the Contractor's License Law(Chapter
f44p 9(commercing wit it section)(mor'Division 3 of the Business and Profession Cra 1. SWIMMING POOL ELECTRIC VALUATION
or that he is exempt hereinto and the basis for the alleged exemption.Any violation of OUTLETS-SWITCIfES-FIXTUNES
F- ¢ Section 70115 hyaryambeim for.permit subjects the.pplicanfto.civil pe..Ity.f
not more than five hundred dollars 0500). SQ.
C _ PT.
Cpm ❑ I,asowneroftheproperty,ormyernployeeswithwagesastheirsolecompensation, NEW RESIDENTI STORIES TYPE CONSTRUCT
y$_ will dothe work,.nd thcslrucime isnot intended ofnffered forsale(Sec.7044,Boss
and Professions Code:The Contmemsr's License Law does not apply to an own
pmpenywbobuildsorimpmvesihereon,wdwhodomssuchwurk himselfnthmugh
prnot
s OCC GROUP RE'S.UNITSTS
own employees, nvidedtha,such improvemenlsam
rt lmiendW orofferedforaal If,
however,the building or Improvements is sold within one ycaro(completion,then er- TAL:
builder will have the burden of proving that he did not build or improve for put seof
rule.).
❑ I.mownernfihepropeny,amexclusivelycommciingwithlicensedcon Cont QTY' PLUMBING P;1 IT• FEE FLOODZONE APN
consumer the Project(Sec.71144,Business and Professions Code:)The Co tmc10l6
License Lowdoes not applyo,m,owneroflrupeny whobuilds m unpmvesth airmail PERMIT ISSUA01
whoempects branch projrels with Acononctur(s)licenad purammmthe Ca neem(,
License,Law. D &VENT-WATIR FA)
FEE SUMMARY
❑ I am exempt under Sce. ,B&P C for this BACK FLOW PROTECT.DEVICE SANITARY OW—TI—DF DES
N—
Owner Dente DRAINS-FLOOR.ROOF,AREA,COND, RECEIPT#
.�
Covers WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihemby affirm,hmihevcacenificate of conxnuo xlf-insert,.rearOficem of RECEIPT N
FIX'T'URES-PER TRAP
CoversWarre1Cmployee,s nlnumnuora ccnifiedcopy,hertof(Sec.JSW,Isb CJ which PARK PEE V N
ars ell employee'¢under this Pertik GAS-EA.SYSTEM- INC,4 OUTLET'S RECEIPT O
Policy BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER 4(IIA) PL AhICHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe Permit is for one hundred dollsre(Si10) SEWER-SANITARY-STORM P.A.200111'. ENERGY FEE
or less.)
I certify that in the performance Ofthe work for which this permit is issued,I shell WATER GRATER WNBN'17ELECTR '
not employ any Perron in any manner so as to become subject to the Workers' PAID
z A,mlumsminn Laws of Celifnmia. Dote WATER SYSTEMrGtflA'fING Dam Reccip,0
Applicam
0 . NOTICE,TO APPLICANT:flimmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB.- SQ.FT. TOTAL:
1n haeunambjeet loth.Worker's Compensation previsions ofthe Labor Cade,you must
funhwith comply with such provisions or Permit shall be deemed revoked, BUILDING FEE
4 [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
.r1. z I hereby affumthat them is a construction lending agency for the performance of 9 I ELECTRIC HEUO�-t the work for which this permit is named(See3097,Civ,CJ
LJ- uLender's Name PLUMBING FEE
Lender's Address QTY, MECHANICAL PERMIT FEE
U 1 certify that 1 have reed thix application end also,that the above information is
c rte s,le ree m comply with all cit y MECHANICAL FEE
g py city ordinances and stem laws rcledngm PERMIT ISSUANCE
F-' 01, building construction.and hcrehy authorise representative oftbis city menterupon me CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save.indemnify and keep hsrmleas the City of Calandra against
liabilities,judgmenu.coslsand<xprnus which may in my way mcroeagainst id Ciry AIR HANDLING UNIT(TO 10,00)CFM)
mconaequemceoftbegrant lsgofthis cnnit.
T />
L AIR HANDLING UNIT(OVER IO.IXp CFM)
Signatuof ApplicanUCOmmctor Daataa EXHAUST HOOD(W/DUC) PAID
HAZARDOUS A AIALSDISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Date R<c t
Will the applicant or future buldig occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T15
m defined by the Cupertino Munici Code.Chapter 9,12,and the Health and Safety
Code,Section 255J2(ep
0Ycs 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP CUP OR 111(1,000 BTU) E ATE
Will theupplimnmrfwurebuilAequipmentcuuse equipment ordevices whichemit Aq D
h.zaMoas air cammninents as defred,hy the Bay Area Air Quality Management BOILER-COMP(OVER IW,IMI(I RTU)
District? APR 27
❑Y. ❑No NEW RESIDENTIAI.MF.CII. SQ.FT. 1995
I have
rend the Safety
Code.
mction,x requir25531 under Chapter fi95 of,he CSI y /Js�
ifth,bmialludoe,no,Curendy have ans25505,25537 o,A,prosi Iundemand that I U1. LLLL ^I�
ifthe builJing Anes not curtcntly hnvon mnan6ih.ti,itmy respnnsibilirymnotify,ha IaVNCal��tl
reception of the requirements which mus,he mel prior m issuance of a Certificate of
Occupancy.
Owner arvtmhnrized tiger, Dam TOTAL: ISSUED BY:
OFFIC