27190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD ING-ELECTRICAL � PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27190
-BUILDING PROJECT IDENTIFICATION: ..
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATF.
\ 0 /'/�W •#�`o0SS-I4IT# LOTH I I ��1�1
OW ME: PHONE: -MIS F.: LI NO: N/C CONTROL#
MCH]flECT/F.NGINEER: LIC NO: ADDRESS: ❑
1177
'ONTACT: PHONE: -C ,
QTY. r .ELECTRICPERMIT' ;,FEE BUILDING PER INFO -
���
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE T k v
LICENSED CONd under OR'SpECLARATION pppLIANCES-RESIDFJJTIAI. JOB DESCRIPTION /t_.
9 0 Ihereby.I'irmtbml amlicemWunss Old
Pribnsime;Coder 9(m(commencing is iM1
z100 Seen.,,all.and of Dlvlsion 3.1'the Business and Pncfessions Code,and my license is In PANELS
tlU
License
and afford. UP TO 200AMPS
-M. Dole Clms Lic.laati
nQZ pate IECTSD 201-IOW AMPS
;on— - ARChiI'1'F,CTS DECLARATION OVER IAdd AM PS SQ.FT.FLOOR AREA $/SQ.F9'.
t] 1 understand my plans shall be used as public records. _ _ `r•}�
y ; SIGNS F,hF.CTktCAL '7L�(]ss�/-}'�'
Licensed Prnfessinnal
IT< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
iF 1 hereby affirm that am exempt from the Contmctols License Law for the
0.rn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
5 O which requires a permit to construct,alter,improve,demolish,or repair any structure
tili�� prior 1.its iNounec,also contacsfie applicant forsuch permit to fileasignedstatemetn POWER DEVICES
tl q p that he is licensed pursuant e the provisions of the Contractor's License Law(Chapter _
LL, 0(commencing SWIMMING POOL ELECTRI
o ( empththerefrom
erefr mad the Division the the Business and Professions Code) VALUATION
orthoheisex by an applicant for
the basisforbjects thedexemountto civiny l Dimity of OUTLETS-SWITC - URES
d Section than
by anyapplicantforapermit subjects the appliwnno acivil penalty of
t moa,than five hundred dollars($500).
ZEw ❑ I,asowneref[hepmperty,ormy employeeswith wagesastheirsolecampensetion, I . .LECI'R .FT. STORIES" TYPE CONSTRUCTION
a will do the work,and the snIsn
ucmre ot intended combined forsale(Sec.70W4,Bas lvess
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimpmves thereon,andwhodoessucliwork himselforthrough his
own employecs,pmvided thosuchimprovementsurenot inteadedaroffered forsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofwmpledon,theowner. TO AL.
builder will have the burden of proving that he did not build or improve for purpose of
solo], 777e r . , . -
❑ I,av nwnuof Ma property amexelusively contracting wrath eed comraemrsm QTY.. , 'PLUMBING-PERMIT , FEB ? FLOOD APN
boen
construct the project(Sec.70144,Business and Professions Core)The Contractor's
License Luwdoes not apply to an ownesofpmpmty who halide orimpmvuthereon,and PERMIT ISSUANCE
who contracts forsuch projects with a comramor(s)licensed parsunnnods,Contractor's ALTER FA _ FEE SUMMARY
Llcmtse Law. (- ) - -
❑ I am exempt under Sm. ,B&P C for this reason BACK I7LOW PROTECT.DEVICE OUTSIDI, ,ES
f SANITARY YN
Owner Dare DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihercby affirm thmlhawaeertificeteof consent mself-insure,...certificatanfPIXTUR69- R'TRAP RECEIPT#
PE
Wnrkere'Compenemlen lnsuranceoraanifal eopY thereof(Sec.3g00,LabCJ which PARK FEE YN
covers all employee's uadenhis permit. GAS-EA.SYSM-I INC.4 OUTLETS RECEIPT#
Policy# TEBUILDING DIVISION GEES
Company GAS-EA.SYSTEM-OVER 4 HIM PLANCHECK FEE
❑ CediOed copy is hereby f nnished.
[I Certified copy is filed with the city inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREA$ETRAP SOILS FLG
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20OFT. ENERGYB
or Iras.J
I cenifythat in the pertormanceofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
no ,3 j
t employ any person in any rammer ubj
so as to become subject m the Worketm PAID
Compensation Lawsof Califomis. Date WATER SYSTEM/IREATING t Receipt#
Z Applicant
NOTICE TO APPLICANN:If,after making this Certificate of Exemption,ymi,hould NEW RESIDENTIAL PUMP. SQ,FT. TOTAL: I�Q�s10
rte. become subject to the Workers Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or permit shall IN deemed revoked. BUIL I GFE --
Q CONSTRUCTION LENDING AGENCY IS E Z
Z I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C,) TO L: EL G
Lenders Name - - PLUMBING .E
l-' Lcnd I o Address QTY ` ' r' ' ' ''ANICAL PERMIT=�' ^"FEE'7
U 1 comfy that I have read this application antl state that the above information is '' '
correct.lagrcerommply with all city andeoanty mod nancesand sate laws slatng to PERMIT ISSUANCE MECHANICLFEE
building construction,and hereby authorize representatives oftbtsedy no emerapon the CONSTRUC'IONTAX,'Z above-mentionel property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmands,costs and expenses which may in any way accrueagainst said City AIR HANDLING UNIT(TO FLOW CFM)
to onseync the granting ofthis petro.
AIR 14ANDLING UNIT(OVER 10,000 CPM)
Slgnautrco pllcanU o .c r as EXHAUST HOOD(W/DUCT) PAID
IIA ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) to R coal If
Will Inc appli,.orfmure building occupantsmre or handle hazardous memrisl HEATING UNIT(OVER IOO,IX10 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Seetl❑Yes 2(e)9 ❑No VENTILATION FAN(SINGLE RESID)
,000 BTU) gapplicantw
Will the applicant orfurebuildingcecupanw
t use equipmentordevices hBOILER-COMP(3HP OR 100
which emit PP ISSUANCE 11
hazardous air comaminmba as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 6}
District? n
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Nf C 71994
sh have read the hazardous mateuals requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,35533 and 25534. 1 understand that V ClJy
If the building does tom currently have.tenant,mat 5t is my responsibility mn9efy the - U♦' LUf'tH11N
occupant of the mqulremems which must be met prior to issuance of a Cenifwte of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE