27309 LAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
TY OF CUPERTINO A' PERMITNO.
BUILDING DIVISION- --AP.PLICATION/PERMIT PLUMBING 2709
BUILDING PROJECT IDENTIFICATION / JJ J
LDING ADDRESS: - SANITARY NO. APPLICATION SUBMT F1AL DATE
D01v / a �n0 k( � UNITM � LOTS'ERS NAk nPHTON: CONTRA 'S AME:1pn/C "V C 71+✓ db Ham/ �� , aa6N/CHITELUI NGINEER: - LIC NO: RESS: ❑
CONTACT:/ PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
",(/rte ) I B� LDG ELECT r MECH
/xJ V ""✓V✓/VV •./4✓` PERMIT ISSUANCE �• l I� IdZ•1(�
LICENSED CONTRACTOR'S DECLARATIONb,mr9( pppL1ANCES-RESIDENTIAL 1rvn�= VI��
pyZ Ihcrchy vffirm lhmlam licensed under provisionsofCTvpmr9(commencing with (I-L�'n
0.100 Section]001),I'Division 3 ofthe Business and Professions Code.and my license is in PANELS
yUF falland effect.
LQ.,ZwVjy License t
License Class LiaN UP TO 200 AMPS
Lic
rn<y Dale Contractor 201-1000 AMPS
Z F0 N Z ARCHITECT'S E TION SQ.FT.FLOOR AREA S/SQ.FT.
O Z—O I undersl y tun 1 p he records. OVER 1000 AMPS
E„ti Irl SIGNS ELECTRICAL
Licensed Profusion;
U
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOyI hereby affirm that 1 am exempt from the Contractor's License law for the
m 3 u-y following mason.Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F J which requires a permit to c.nswct,atter,improve.demolish,m repair my swctum
2`o rt
}., prior its issuance,also requires the applicant for such pemdtro file a signed statement POWER DEVICES
WC¢0 that he is licmrsed terminal to the provisions of fi a Contractor's License Law(Chapter SWIMMING POOL F.LF.CITtIC
1L.X 9(impr cin,wilh Section Division 3oflhe Businessand Professions Code) VALUATION
or that he is exenr t lhomfrom unit the basis fn,hc aIle ed introspect.An I ion of
W=m p g Any OUTLETS-SWITCHES-FIXTURES
FZQ
Section7031.5
five
anyapplidolltrs($50mrit subjats the applicanuoacivil penehy of
KFonot more than f ve M1undred dollen(SSW). NEW RESIDENTIAL ELECIR _SQ.FT.
❑ I.asownerofthepropmy,ormyemploymswithwagesu Neirsolee mpemadon, STORIES TYPE:.ONSTRUCI'ION
a3°O will dolhework,and the structure is not inspired mothered forsae(Sec.]019,Business
and Professions Code:The Contravenes License Law does not apply to an owner of
propcny wholoild,caiarprove,memos,and who does such work himself.,through his
own employees,provided that such improvements are not imcaded oroffered trawls.If, OCC.GROUP RES.UNITS
however,the building orimpmvemem is sold within one yearofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale)' QTY. PLUMBING PERMIT FEE ROOD ZONE APN
❑ Las ownerjeNe PropSec.7y,1,Business
ntrvning withde)Th Contractor's
i,roal the project(Sec.'/019,Ousiness and Professions Code)The C.mmctor's PERMIT ISSUANCE
License contracts aw dresnm apply m nn uwncomme pent'wh.sed puomear to the Conti actors
whenseLw.lbrsuch projm¢with oeonvncmr(s)licensed pursuant to the Cnmruemr's A11fER-DRAIN&VINT-WATER(EA) FEE SUMMARY
License Law.
"❑nI am exempt under Sm. ,B&P C for chis renvon BACK FLOW PROTECT,DEVICE OUTSIDC FIeES
SANITARY Y N
Ownm Date DRAINS-FLOOR.ROOF.AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
r� ❑ Thereby affirm lhatl have a cenificam ofconsenno.cif-insure,macenificumm' FIXTURES-PER TRAP .► RECEIPT#
Workcrn'Compersttion lnsmaneenr a rnifiod one,lheroof(Sec.38W,Lab CJ which PARK FET? Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4OUTLETS RECIU PT#
PoIcyN - BUILDING DIVISIO FF
❑ComICrnified co,ishereby famished. GAS-FA.SYSTEM-OV ER4(EA,) PLANCIIECK FEE
❑ Certified copy is filed wird Ne city inspmf division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE -
CERTIFICATE OFIiXF 'ION FROM WORKERS' . GRIiASETRAP SOILS FIiIi
COV ION INSURANCC Pq
(Thissmtionneadmike pletedif Nepernilisforonchundr A-d Iars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGYFF.E
or less.)
l artily the' Hormmaoflbew.rkfnwhichthispnmitisie ed.I shall WATER((EATER WJVEpnELECIR
not empl y any person in any manner so az in become subject m do Workers' PAID
Compact:Zion laws of Califomia. Date WATER SYSTEM(TRGTING Uate Receipt#
O z Apphcm NI3W RESIDENTIAL PLMB. SQ.FT.
zC) NOTICE 10 APPLICANT:If,afmrmaking this nificamof Exem o , 1a should
become. bject to the Worker's Compensation pro 's on' f the l-a must
� > fortbwi comply with such provisionsQ M1is (shall bj d� BUILDING 19iE
SEISMIC FEE
4. Q CONSTRU ON , ACV
1 rcby affi menthe [ di cy for Ne ortnmc<of
U z T ' ELECTRIC IEEE
the wor for which a ed(Sc 309 iv.C.)
Is ovC Name
4r•. I"' Lender Address= a s QTY. MECHANICAL PERMIT FEE PLUMBING F17F /•
V I enify Nal 1 h. e d Oris application vrd nate Ih a above information is MECHANICAL E
�" W corrta lagrce neon Ixi@ell city aod county.Niru es and stem laws relatingto PERMIT ISSUANCE
F' a' buildin construction,an hereb thoriurt reunm- <sof lhiscit mmmru the •1
rA yon p y fib^ CONSTRUCTION AX
U z above- emioncd#,very for mapeaiun puryoms ALTER OR ADD TO MT:CIi.
p q agrcc m save.indemnify vnd keep mb"o the City of Cupertino against
liabili... .judgments,costs and expomwwh' y w.yaco-.ca,ainnmin Coy AIR HANDLING UNIT('101g000CFM)
t th ermting o'dox n.
AIR HANDLING UNIT(OVER 10,00)CFM)
Signature of A 'tor Dam EXHAUST HOOD(W/DUCD - PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.000 BTU) Data Receipt#
Will the the Cupeant rtino
Mu building de.Camsorao,and th Heaadous lth and
aterial
Safety HEATING UNIT(OVER 100,000 BTU) T
as JefineA by;he Cupminn Municipal Gde,Chapter 9.12,and the Health unJ Svfety
ll
Coda Section 25532(.)) VENTILATION FAN(SINGLE RFSID) C
❑yes ❑No
ISSU NCE DATE
Will the applicanmrfuwrebuilding«captor uxequipmentardeviceswhichemit BOILER-COMPOHP OR IW.000 BTU) N�
knomdous air conmminanu m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) N A
listrict? A. b
❑Yes ❑N. NEW RESIDENTIAL.MECI1. SQ. •Y
Lca-wf
mad the hmard.us materials"wrements under Chapter 6.95 of the oYa 7nalth&Safety Code.Section.25505,25533 and 255]4. 1 undrsand Nat1J does not currently have a tenant,that it is my responsibility to notify thehe requirements which must be met prior to issuance.f a Certircam of h (u �)/r,J/horived agent DamFr9I ISSUED BY: a'Iu
OFFICE