27265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEUMUCAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27265
.BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: J{�/��������/j(��[�� SANITARY NO. APPLICATIONSUBMUTALDATT
Rew Q�yV�t� )YWIUNITO LOT# �I �
OWNpp' C: PHONE: C NTRACfOR'S NAME: LIC NO: NIC CONBOL#
V\ 1 �J
RCIIITIiCI'/ENGINEGR: LINO: DRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INEO
8{.I)/f PLUMB MUCH
� PERMIT ISSUANCE (JLfJG`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENDAL �a,,,� N
y
pL Ihereby affirm that lam licensed under pmvisionsofCTaprer9(commencing with (40 El
WCO Section 7000)of Division Sof Ne Business and Professions Code,and my license is in PANELS
<Z, full force anile
(a.,Ztu License=Lic.#� UP T0200AMPS
m?y Date Conuacmr 201-IOOOAMPS
ZOyZ ARCHITECTS DECIARATIO OVERIVKAMPS SQ.FT.MOOR AREA $/SQ.FT.
0Z_C1 Imabrimed ra,,Ims,hall beuacd as publi,emools.
F F' SIGNS ELECTRICAL
Licensed Professional
dad 0.'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC.
xx0.00. I hereby affirm Nm 1 am exempt from the Contractor's License Law for the
W 4 a following crown.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which reyuires ii permit m conswet dor,improve,demolish,or repair any swetmer
ce,WY7 prior m its issuance,also requires the applicant for such permit to rile a signed summenr POWER DEVICES
W 0.O0 that he is licensed pursuant to the provisions of the Conusmoes License Low(Chapter
0.X05 9(commencing with Section 70010)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
VALUATION
W:2,q or that he is exempt thrrefmm and the basis for the alleged exemption.Any violadon of OUTLETS-SWITCHES-FIXTURES
1=Z Q Section 7031.5 by any applicant for a omni,subjcc¢the orPliam m a civil pemlty of
..=< not more than five hundred dollars($SM).
mtm ❑ Lasowner(ifNepmperty,ormyemployceswithwagesmtheirsolecompemation, NEW RESIDENITAL ELECB _SQ.PT. STORIES TYPE CONSTRUCTION
0.3— will doahnwons andthe he Contlsnot is License Lawrdolmot apply Loan,Business
and Professions Code:The Contractors License Lew aers not apply lf an owner of
own
propen,who buildsorimprovesth improvements
who are sou chworkhimselfoul Enough his
employees,holding- istsuch
i,vememsamne etuidedmoffered fo.w If, OCC GROUP RES.UNITS
buwcveq itIhav l tie burden
rimpmprovin ishat he did
nnt build or improve
for purpose f L "
builder wit I have the burden of proving thin he did not build or improve for purpose of
a).
❑ 1.asownerol he propertY,am exclusively contracting with licensed contractor to QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
construct the project(Sm.7044,Business and Professions Code)The Covuactors
License Lrwdaes not applyto anownerofproproy whobuildsorimproves domes,and PERMIT ISSUANCE
whocnmrmts for such projects with aamtmetor(s)licensed pursoca tto the Conractors
License Law. &vFNT-wA'1'ER(EA) FEE SUMMARY
❑ I wn emmpt under Stt. ,B&P C for this reemn BACK FLOW PROTECT.DEVICE OUTSIDE MES
FF
Owner Data DRAINS-FLWR.ROOF,AREA,
WORKMAN COMPENSATION DECLARATION IDOLX
❑ I hercbyaffirn that l hxvearciificateofcoment msel6icamea.marem catuf FIXTURES-PER'I'RAP
WorkersCompensotinn Insurance oracenifieJ copy thereof(Sec.3g00.1ab .)which
coven ellempluyces'under this permit GAS-EA.SYSTEM-I INC. 0UTLE1'S
Policy# BUILDIN
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTGM-OVFR4(EA7 KME
❑ Certified copy is filed wird dm city inspection division. GREASE/INDUST STET RCEPTOR 3E
CERTIFICATE OF EXEMPTION FROM WORKERS' E
COMPENSATION INSURANCE
(This section need not be completed iftbepemrit is for one hundred doll ($100) -R-SANITARY-STORMEA.20k) E
or hes.)
IcerifytharinthepeRommnee of the work for which Ibis permit is issue Ishall TER HEATER W/V NgP,I.'E
not employ arty person in any meaner so m to becmne subject to the roars'
z Grmprmarion Lawsof California. Date WATER SYSTEM/TREATING Dam Applicant7, C) NOTICE TO APPLICANT:If,afmr making this C
enificoteof Exemptiomyou shout NEW RESIDENTIAL PLMB.
1• lin become subject to the Workers Compensation provisions ofthe Labor Code,you must
04 forthwith comply with such previsions or this permit shall he deemed revoked. BUILDING FEE rat
y Q CONSTRUCTION LENDING AGENCY SEISMIC FEE ^>
U z I hereby affirm that there is a conservation lending agency for the Performance of Cr
U O the weak for which this permit is issued(See 3097,Civ.C.) TOTAL: ELECTRIC FTSE
Lender's Name
ULeader Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that T have read this application and stain that the above information is
come,. I agree to comply with all city and county ordinances and sum laws relating to PERMIT ISSUANCE MECHANICAL ME
building construction,and hereby authorize represenmtives orchis city menmrul0n the
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to.save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmeraccosrs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
in conseyuenec of the granting c f this .it.
u AIR HANDLING UNIT(OVER 10,IxO CFM)
Signa a Apphim Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dom Receipt is
Will the applicant or future building ewrapml store or handle Imomdom material
as defined by the Cupertino Municipal Code,Chapr,9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Gee,Seaton 25532fu)?
El Yes 0 N VENTILATION I-AN(SING LE RESIDE
Will s air coricamnces, edefir d by the Bay A.Ain Quality
es Marsonchemh
BOILER-COMP(3HP OR 100,000 BTL) ISSUANCE DATE
rvrdous yr comaminanb m dcrincd by the Bay Area Air Quality Marmgemem
District? BOILER-COMP(OVER 100,000 BTU) D
r
r ❑Year ❑No NEW RESIDENTIAL MECH. SQ.FT. kpy�
1 have rtad the hmardous material,terminations ander Chapter 695 of the OYo I] n�
California health&Safety Code,Sections 25505.25533 and 25534. I understand tho 1J
at
fif[lie onilof']oring erel eurec,d,have a which
r ethat it is myssuance off. Comtism the C//r
occupant of the reyuiremen¢which must M met prior to issuance of a Certificate of H Ur LUf
Is
Occupancy.
CY(I
Owner nr uuthonmJ agent Dam TOTAL: ISSUED tlY
OFFICE ��