27388 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.MECHANICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING GFitoi -MECHANIFICA
BUILDING DIVISION BUILDING I'MOJECI'IDENTIFICATI4)N 27388
IIUILDINGAIIDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�O UNIT LOTX
OWNS IS N41MU r PHONE: C CTOR'S A LIC NO: I
'e -tsfjSj1S N/C CONI'ROLN
RCHITECT/EN IN R: LIC NOTA ADDRESS: ( ❑
-ONTACf: PHONE: QTY. (/O ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE Ip1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, f� LOB DESCRIPTION
Owz I hereby4flmr that l rum licensed underprovisionsofCapter9(commencing with
POO Section 7a")of effcivision 3 of Ne Business and�Professions Cade,and my license is in PANELS
"Z I.icenu I✓s _ LIL.N �7✓-kl UP T02W AMPS
Ca<y pate Contras 201-11100 AMPS
Z ONS ARCHITECTS D: I. OVER IOW AMPS SQ.fT.FL000.AREA M.FT.
O Z 2,M I understand my plans shall be used as public records.
y F SIGNS ELECTRICAL
4F Licensed Professional
wJ N OWNER-BUILDER DECLAMATION SPECIAL CIRCUIT/MISC.
5°5�'OyU 1 hereby effimt Nat 1 am exempt from Ne Conuoctola License Lew for the
u13Ry following reason.(Section 703).5.Business and Professions Code:My city or county TEMP.ME -R OR POLE INST.
which requires u permit In construct,alter,improve,demolish,m repair my structure
}� prior to its issuance,also requires the applicant forsuch Permit o File a signed statement POWER DEVICES
m p p that he is licensed pursuant m the provisions of the Contractors License law(Chapter
L oL i
9(commencn with Section 7000)of Division 3 of the Business and Pinfesslons Code SWIMMING POOL ELECTRIC
oW 8w ) VALUATION
W❑y or that he is exempt herefrom atoll the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F-ZQ, Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of D D
O
not mom than five hundred dollars MOO). NEW RESIDENTIAL ELECEN _SQ. .
Ff
e ❑ I.mawnerofffic M)arty,ormyemployeeswithwMautMirsolecomp oration, STORIES TYPE CONS'IRUC'1'[ON
l4. willdo the work,and dr amewte is not imershalmoffced fmsale(Sec.7044,Bod.
and Professions Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves Neuron,and who does such work himselfor drrough his OCC.GROUP RES.UNITS
awn employees,provided that such impmvemen B ere not i mended or offend for sale.If,
however,the building or improvement is sold within one year ofcompletion,the owner-
builderwillhavetheburdenof that be did not build or int for f TOTAL:
salproving prove puryaseo
e.). L
❑ 1.asownerofthepropeny,amexclusivelyconimctingwiNlicensedconnctonm QTY. P MBING PERMIT FEE FLOOD ZONE AL
IN
Ne project(Sec,7044,Business end Professions CWeJ The Contractor's pERMI SUANCB
Liavelawd«snot applymanownenofpnryerrywhobuilds orimpmvu Hereonand I 2--d9(l
whoeontrcrforsuchprojatswiNacantmmm(s)limnsedpunuantwthe Con=toes L R-DRAIN VENT-WATER(EA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK.a .DEVICE SANITARY Y_N
IQ
Owner Date DRAINS '1. ,ROOF,AR ON RECEIPTN
WORKMAN COMPENSATION DECLARATION A SCHOOLTAX Y N
❑ Ihaeby affirm dntlhaveacrnificweofcansemmsdLinsurc.oralxrtifica'a ( PER Qq RECEIPTN
Warkers'Compensation ltnumnceor a cerifiedcapy theteaf(Sce.39M,Lab C.)whi ��' V PARK HE Y N
ars all employ, eu is pcmi �/ .SYSTE -1 .4 Of Im RECEIPTN
Policy N 7 BUILDING DIVISION FEES
Company R NS G - -0 ER4(EA PLANCHECK FEE
❑ C,ififildo.pryisherebyfurchaded.
❑ 11kFVNDI9TRL WASTTI,6iTEkccPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRt ETRAP SOILSFEE
COMPENSATION INSURANCE
(This section used not be completed ifthe permit is for one hundred dollars 1f 100) SEWER- NITARY ORM FA.2WEf. ENERGY FEE
or less.)
I certify that in the performanceoRhework for which this permit is issued,].hall WATER HEATER W/VEIG-JULECfR
not employ any person in any manner so as to become subject to the Worker' PAID
I Compematiou Lawsof Califomia. Date WATER SYSTEM(TREATING Dam Rtteiptp
Q/z Applicant
Q NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
rq become subject tothe Workers Compensation provisions ofthe labor Code,you most q
� ; forthwith comply with such provisions or permit shall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEF,
s�
^� 1 hereby from Maumee is a construction lending agency for rhe pMonwnce of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: OO ELECTRIC FEE
Ltr Linalio',Name - d
0 [ Lender's Address Q'fY, MECHANICALPERMIT FEE PLUMBING FEE
V I certify that 1 have reed this application and stale that flue above information is
acorrect Isg=m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
CA building construction,and hereby authorize representatives ofthls city wenterupon the CONSTRUCTION TAX
V z above-mentioned property for inspection prolamines. ALTER OR ADD TO MF.CH.
(We)ogre to save,indemnify and keep hamiless the Ciry of Cupenimo against
liabilities,judgnicat osHand aNscrics wbBb Mayin ny way accrveugainst sold City AIR HANDLING UNIT(TO I0,IIW CFM)
me cut Ipnnl' T.
AIR HANDLING UNIT(OVER 10,000 CFM)
-I S Data
Signou fApphcanT/ onus r Dete EXHAUST 11000(W/DUCT) PAID ,;L:j � --�--, -•
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I 00,000 BTU) Date - e erpt i--�
Will theiind,antnrfuwre huilding occupant nnre or hvndle bazwdoue materiel HEATING UNIT(OVER 100,000 Bill) TOTAL: !�
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cada,Section 25532(n)7
0Yes 13 No VENTILATION PAN(SINGLE REBID)
Will Me oplithemmfuture buildingoccupant urioptupmenmrdevicca whichemb BOILER-COME(311P OR 100,000 BTU) I9SUANCEDATE 'G�v1—A
iazanloua it contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100.001)BTU) ,'J` CGWi G iJ l Lz
Onto?
11FEB 15 1995
Ycv ❑No NEWRESIDENTIAL MECfi. SQ.IT.
1 have read The heaefdous materials requirements under Chapter 6.95 of the /s
Califomio Health&Safety Code,Sections 25505.25533 and 25534. I understand That C/1 r Vf NUf Cf1111VU
if the building does not currently have a tenant,that it is my responsibility to notify the
Occupant of the requirements which must M met Prior to issuance of a Certificate of
Occupancy. e /
Owner or authorized agent Date TOTAL: ISSUEDB C
OFFICE