27739APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO intPERMIT NO.
APPLICATION/PERMIT PLUMBING. MKCHANICM I� f Q
BUILDING DIVISION BUILDING PROJh1CT UMNI G r
73
BUILDING ADDRESS: SANITARY NO. APPLICATION
SUBMITTAL DAT
UNIT# LOT#
OWNERS'N ME: U9074� PHONE -Ob�^ CO ACTOR'S NAME: LIC NO: NfC (�CONIRDOL#`
G, U
HC liCl'RiNGINEBR: IC NOM QTY. ELECTRIC PERMIT FEEE ADD ,,EP
wyq,4 bb
4 I _�� / `ae ❑
CONTACT : PHONE: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LthatIa,D CONTRACTORSsed ndcrpmDECLARATION APPLIANCES - RESIDENTIAL
Z Ihcre0),I' mum l3 ofth Business
isionsions Core. sucommencing with JOfI DE RIPTION
O
Section ?add ffiem sion3of the Buainess and LRofessions Code. and my license Bin PANELS
full force and effal. aa�a qq ���� 41 / 9 UP TO 2W AMPS
tp Date Cluss�` Lic.M
so Dam Cnmrnnor ?W f 201 - 1000 AMPS
Z ARCHITECT'S DECLARATION
O 1 understand my plans shall be used as public records. OVER 1000 AMPS SQ. 11'. FLOOR ARTA VSQ. IT.
to
SIGNS ELECTRICAL
....II Lecnsed Proleaswnal
U OWNER -BUILDER DECIARATION SPECIAL CIRCUIT/MISC.
[— I hereby affirm that I um exempt from the Convacmrs License Lew for the
in following rcason.(Seaiun?W1.5, Business and Professions Code: An county TEMP. METER OR POLEINST.
which requires a permit b constmeL aper, improve, demolish, m any s tore
S that he it.iswana.alsoreynhesme apsionsofthe Commair casal-ineum m POWER DEVICES
O that he is licen. A pursuant m tM1e provisions of the Convect License law (Chept
R4 Y that he is ixemitM1 therefrom
Division3fienthe all
els uJ Profession Cod e) SWIMMING POOL ELECTRIC -VALUATION
.� ontin M1703exemptny applicant for
the haspe 'Isubj ell exemption Any violation ofSect inn OUTLET'S -SWITCHES -
Q amams, the 56ya udrddo][forapesmitsubj de plicannoa<ivil ehy of FIXTURES
p nm momthanfivsf EeprWdollars (E500). NEWRESIDENTIALELECIR S ET.
m ❑ I,asowncrof mepropeny.ormyemp swish s heirule o Q STORIES TYPE CONSTRUCTIOD
will dome work, and thcswcmre land endedo "I alter. Busine
and professions Code: The Co. or's Licenu Ln s not ly y of
propenywhobuildsmimpr .thcrcdn,anJ wh .uch wr effort ghbis
employaasmm
s,provid chimprovemgtss� notimcndM o ratite. If, OCC. GROUP RFS. UNITS
builder will have the bu nun ma idnnrjmpr for puryou of
sale.). v
TOTAL:
TY. PLUMBING PERMIT FEE
❑ Lasdwnerofthe r n bclyconva lin n corwilimanchrst.
pe y,a
icartw she proose, moect ( c ?U94, Basinva". d Profession od J The Cdnva , and
LlameLuwdoesnm cep Loan dwicof •eywhobu' sorimrotheCercomand
wbdcummcu rorsuch pro uwimawm gs)licen pursuanuothe Conaaaor's
ROOD ZONE
APN
PERMIT ISSUANCE
-
Licenu Lew.
❑ 1 am exempt under Sec. B
ALT IilL DRAIN &VENT - WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE, FEES
& P C for this mmdn
OwnerSANITARY
Data
YN
WORKMAN COMPENSATION DECLARATION
Unica lherebyaffivm ma l base a cenlEeme ofconsanuowif-Insure, or a ceniGcme of
mkers'Compenution lnsuranec orecenifird mereoflSa.3800.
DRAINS- FLOOR, ROOF, AREA, COND.
RECHIFTM
SCHOOL TAX V—N—
RECEIPI'M
FIXTURES - PER TRAP
PARK FEE Y N
HECF.IPI' N
copy Lab CJ which
covers all employee's under this pcnniL
Policy N
GAS - EA. SYSTEM.I INC 4 OUTLETS
Company
GAS . EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
❑ Certified copy is hereby furnished.
ished.
PLANCHECK FEE
❑ Cendied copy is filed with the city inspection division.
GREASF/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS PEE
('Otis section need not becomple>difsbe permit is fondue hundreddollars O ffi
or less.)
SEWER - SANITARY -STORM EA. 201 a
ENERGY FEE
z
* 0
Fy
I rectify that in the performance ofthe work per, which this pFnmit qis issued, I shall
m employ any person in y acinar b eyY me Workers
Co mperssasionlawso forv�/li IY'
Applicant L"/�
WATER HEATER WIVENT/ELECI'R
PAID
Date Receipt
WATER SYSTHMp'REg riNG
NOTICE TO APPLI ANT:If,uter making this CeniEcum of Exemption, you should
become subject o the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ, ET.
TOTAL:
a;
pW, Q
Z
V O
OU
W
F 6.
f0
O Z
fonhwish comply with such provisions or this permit shall be deemed rcvokcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a conseuction lending agency for she performance of
me work for which this permit is issued (See. 7091, Civ. C.)
Lcndde Name
BUILDING PTSE
SEISMIC ME
ELECTRIC P HE
Lender. Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
\
I cenify that 1 have read mis applic dmn and sure thin the above information is
adored. lagreavocompl,,vuhallciyinicounry ordinances and sum laws relining to
building construction, and hereby authorize repcianusivesofdeis city to enter upon the
above-memmnW propcny for m7 donpurposes.
(Wq agree m save, indnnnify and kap l the City of Cupenino agvnst
liabilitim unare enss, vi=w2ary way accrue against said City
in amsxi,j, a the actinAIR
PERMIT ISSUANCE
MECIIANICALFEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT(TO I0,W0 CFM)
HANDLING UNIT(OVER i0AykdCFM)
Signuw App icanv vuemr Date
EXHAUST HOOD OVIDUCT)
HAZARDOUS MATNRIALSDISCLOSURE
Will me applicant or future building occupant sure or handle hazadmrs mmeriul
as define by the ndM,p., eaanaety
CodeSecton 25532yid? /
PAID
Dem HccciptN
HEATING UNIT (TO IOO,IXp BTU)
HEATING UNIT (OVER I W0BTU
'OTAL
VENTILATION FAN (SINGLE RPSID)
•
-d
❑Yes
WilhMapplicant dr fmurebuildingacupantuuequipmentnr deviceswhicIt emit
o
harodhazardous cnmaminnts u. cline) by dee Bay Area Air Quality Management
BOILER -COMP (3HP OR IOO,IXp BTU)
ISSUgA NC11i1,D'ATE
BOILER - (
COMP OVER I W,000 BTU)
I
❑ Yes No
1 havercwl the hazanious materials requiaments under Chapter 6.95 of she
CulifomiaHwhh&Safety Code, Sections 25505, 25533 and 25574. IundersWnd mat
if the building does not correctly have a tenant, deal it is my asponsibiliry b notify dee
Oce yxvcyf the requirements which must be mel prior b issuance of a Cenificme ad
p�Cn • •��
UrL�!
U1
GIS
NEW RESIDENTIAL MECII. SQ. ET.
BY:
Owner or authorized agent Dae
TOTAL: ISSUED