27690 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOfE16D -.1.L FRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /J (]O
BUILDING DIVISION BUILDING PROJECT IOP,,NTIF'ICATI(FN G J
BUILDII/NGADDRFSCS: ,I/� /J SANITARY NO. AP%JCATIONSUBMIITALDATE
/ In4le- i l NIT# LOT It
F.KS NAME://�� PHONE: CONTRACTORS NAME: LIC NO:
VUU L p -X I � Q NIC COM'ROL N
.ARCHITECT/ENGINEER: LIC NO: ADTTRESSl
Yo v
CON'I'ACI': PHONE:
QTY. ELECTRIC PERMIT FEE HUILDINC PERMIT INFO
BLDG ELECT PLUMB MEC.,
PERMIT ISSUANCE El ❑ VIims
'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL f
po4Z Ihembyaffitm that l am licensed under pmvinum, angler 9(commending wish JOB DESCRIPTION
X00 Set 7000)of Divis on 3 of the Busincsxsnd ProPoLS
Osdons Code,and my license is in PANE
<,F. nsfullforc claJeffecL
Z,� t
6- license Chas LIC.g UP TO 2M AMPS `JrFIJ/l��—rf/y—fa '
y6y D:vc Contractor 201-10DIAMPS
ZO.V'i+ ARC]I I'IFCFS DECLA RA'I'ION OVER IINIUAMPS SQ.PI'.FLOOR AREA SISQ,FI'.
OZ-0 Iundenaandm plans shouldLa!medir,publierected,
F-y�LL kP SIGNS ELECTRICAL
¢,Lf; care Professional
z C OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOy 1 hereby amm Nm pt
rat 1 aexemfrom the Conuno
ar's License Lew fm he
m 3 LL y following reason.(Section 7031.5.Business and Professions Codr.Any city or county TEMP.METER OR POLE INST. 1 I, IN
F 4 0 which regainer a pe.i,to canmme,alter,improve,demolish,or repair any structure r _
f' > to its issuance,also re the licant for inch Permit rile a signed statement POWER IW.VICFS
prior quirts pp perm+ gn
W Cz) that he is licensed pursuant to the provisinm of the Contractor's License Law(Chapter (.
a1�oLL 9(commencing with Section 7000)of Divisinn 3 of the Business and Professions Cute) SWIMMING POOL ELECTRIC VATM110yr
❑y nnbut heNexempt therefrom and the basisfonhc alleged exemption.Any violation of
FZY Section 7031.5hyany applicanddrapernifsubjects the applicantlnucivllpcn.lIy,,f OUTLETS-SWITCHES-FIXTURES DATE
ASO notmore Nan rive hundred dollars(S51NB. NEW RESIDENTIAL ELECIR —SQ.FT. STORIES ONSTRUCTION
ry F-o ❑ I,aowneroflhepropcny.ormyemploymswilh wages as lheirsolecmnpensanon,
6'322 will do the work,and the structure is not intended oroffcred forsale(See 7044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whobulldsmor,m vesthereon,andwhodoessuch work himselforthmugh his
dedthat such int mnttarom tintendedoroffered fm sale.If, OCC GROUP RFS.UNITS
emp thees.pmvi prove
builderwthebuilding orimprovement ishathwithin ot build or comm efor purpose f TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
sale.).
❑ Las ownerofthe property,amexclusively contracting with licensed contractors to QTY. PI,UMEING PERMIT FEE FLOOD ZONE APN
Linstruct the project(Sec.Tsl Business and Professions Code:)*Me Contractor's
lcenac Ury Jawsnsapply munownerol lmnpeny wM1obuilds nrimprnves thernm.and PERMITISSUANCE
whmm�trnetsfarsuch pnsjectawilhxenmTar, 0)licensed pursuanno the C..mraewr's ALTER-DRAIN&VENT-WATER(IEA) FEE SUMMARY
License Law.
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner DateDRAINSFLOOR.ROOF,AREA.GOND.
RECEIPT'N
-
WORKMAN COMPENSATION DECLARATION SC11001.'I'AX YN
❑ ers'Co Compensation
ora remaf conummul(Sec.38 m Lab C.)which Fl%TURES-PER TRAP ftECE1PTN
Wvers a'Cmploye'snlmurana nracenified copy Nertof(Sec.3800.Lab C.)which PARK FEE Y N
coven all employee's under this pem+iL GAS-FA.SYSTEM-1 INCA OUTLETS RECCIPTN
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHE'CK FTE
❑ Certilled copy is hereby furnished,
❑ CenilicA copy is fled with the city inspwtian Ji vision. GREASEINDI)S'I RL WASTE,INTERCEPTOR GRADING REI:
CERTIFICATE Oh EXIiMPI'ION FROM WORKERS' GREASETNAP SOILS FEE
COMPENSATION INSURANCE
('Phis section need not be completed ifthe permit is torrent,hundred dollars($100) SEWER-SANITARY-ST'ORM EA.20BP1'. ENERGY ITE
or less)
I minify that in the performance of the work for which this pcmtit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any m m m become subject m the Wmkars' PAID
Calf'ornionhwsofcliffrmi.. Date ha WATER SYSTE I)TREATING Date Receipt If
O Z Applicant
0 NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should NEW RESIDENT IAL PLMB. SQ.FT. TOTAL:
Z In becsnnezubject to the Worker's Compensation provisions of the Labor Code,you must
torr hwim comply withsuch provisions or this permit shall be deemed revoked. BUILDING FEE
(� CONSTRUCTION LENDING AGENCY SEISMIC PEE
z I hemby affirm shot here is a mnsuuction koximg acre,for the performance of TOTAL: ELECTRIC REE
V O the work far which Nis panto,is issued(Sec.3097,Civ.C.)
tenders Name
�- TY. MECHANICAL PERMIT FEE PLUMBING RETE
F IsndIv Address Q
U I unify that I have read his mpplicminn and.,at.that the aboveimfmmatian is MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and studs law s reluting uo PERMIT ISSUANCE
V) building construction,and hereby authorize representatives ofthiscity to enter upon the CONSTRUCHON TAX
U Z above-mnniuned property for impeaiun purposes. ALTERORADOTOMECIL
We)agree to save,Inde airy and keep harmless the City of Cupertino against
Iiubilides.judgme costs expenses which may in any way accrue agaimtsuid City ATR HANDLING UNIT(TO I O.WCFM)
in conse,ci n he gm: gal this+-rail.
/ / _ n¢fZ AIR HANDLING UNIT(OVER IO.000 CPM)
jgnam f do, counselor Dale EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO Ind. BTU) Date Raeipt N
dIthe licam or futon buildingoceuandsmrecr handle hazardous mneriil
as defined a Cupertino Municipal Cale,Chapter 9.12,add the Health wed Safety HEATING UNIT(OVER IW.IXIO BTU) TOTAL:
Cele.5e n255R(a)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will thcnpplicwmrlmurt building occupantuse equipment ordcviccs whichemit
BOILER-COMP(LIP OR 100.000 BTU)
• l+aznrdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPUVER IW,(IB)BTU) q
Di.ek'?
❑Ycx El No NEW RESIDENTIAL MECH.—SQ.FT. A
1 bass read the haeardous mmerials requirements under Chapter 6.95 of the NOV 29 199
California Health&Safety Code,Sections 25505,25533 and 25534. 1 unda
ersnd that 4
if the building does not currently have a lemma,thin it is my responsibility to notify Ne
rccupanu of the requirements which must he met prier to issuance of a Certificate of C0 ser ma
Oceapaney. irr t,1 I TIYV
Owner or authnrieed agent Dae 1.. ISSUED BY:
OFFICE