27608 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ORCUP.ERTINO HILL I .-LLEC'RI AI, PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 7 6 0 8
' BUILDINGDIVISIO+N BUILDING I'ROJEC'T IDENTIFICATION
BUILDING ADDRESS: IQiSANITARY NO. ,APPLICATIONSUBMfITALDATE
0386 Na 0ll• UNITp /QYI V LOT z '
O F.R. NA PI ONE: CONTRACfOR'SNAME: LIC NO: N/C { CONTROL#
Ps-6aao h cr
•ARCIIITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
1 Lf QTY. ELECTRIC PERMIT FEE
Ife C'O'P 7L--- 9 $S=-6D6/ PERMIT ISSUANCE BLDG ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �K!} JJOOOYBB DESCRIPTION
pyZ Ihereby affumthat l am licensed undapmvisiomsafChapmr9(commencingwith
uF1 W fatfame mad of Division 7 of the Business and Professimn Cade,and my license is in PANPIS ^�
Fq UA full Tomeandeffect. J`� U
Z Liumse Class Lic.p UPT02QOAMPS
ti6y Date Coatroom f01.1000 AMPS
zC1 z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OVER IM AMPS
c z P l understand my plans shell be used ter public records. 7
Jm1- SIGNS ELECTRICAL /� I\^
y5� 1.11mucdProfessional p[ V
RM6 OWNER.BUn.DER DECLARATION SPECIAL CIRCUIT/MISC.
Xis. I hereby affirm that I amexempt from the Conuanors License law for the
�40a following reasns.(Section l031.5.emincssand Professions Code:Any city ormenty TEMP.MEMROR PULE INST.
y which requires.permit m conslmct,ri mr,improve,demolish,or repair any strucmrc
f�e]Y7 priorm its issuance,Wsorequires the applicant for such permit to file u signed statement POWER DEVICES
Haj K
<0 that he is licensed pureuant to the provisions of the Contractor's License Law(Chapter
dXOK 9(commencing with Section 7000)of Division 3 of the Business unit Professions Cade) SWIMMING POOL ELECTRIC VALUATION
yI_LLm Smithst 703 .5 by
exempt romund the Permit for
to civiny l
of OUTLETS-SWITCHES-FIXTURES /f// Cary
7rnet more anfis hembelicontfor a rs($50rmit eubjecb the applicant toacivil penally of C b J i
G net ml,mownerofthndreddoliormyom). NEW RESIDENTIALELECTR S FT.
n❑ L ue..,k,afthe Properly,e inion ployeeswithwagaasthe(See.7ompensiiess Q' STORIES TYPE CONSTRUCTION
3 will do Ne,i.nr Corte he Ceramic,
imic intent ase,Le di,s,real apply 1 it Business
pad Pmfwham Code:The Cantranor's ndwhe Law Jas not apply to an owner of
properly whobuildsorimproves thereon,and whodocs such work himselforNmugh his
If, OCC.GROUP RES.UNITS
awn emplayces,proviJed tM1at such imprnvcmems are not imm�deJ or offercJ for sale.
however,the buildingm improvement is sold within one yeueofcompletion,theowna TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
rude).
❑ hasowncrethe properry,amexclusivelycomoseling with licensed contmetors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
misnomer the project(Sec.7614.Business and profcssioms Cade:)fine Convenors PERMIT ISSUANCE
License Law does not all an owncrofpeopety who builds or improves therms,and
whocombels forsuch projects with a contractors)licensed pursuant to the Contowmre ALTER CA
License Law. HEA) MESUMMARY
❑ 1 am exempt under Sec. ,B&P C for this moron BACK FLOW PROTECT.DEVICE U I SIDE FEES
SANITARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
• ❑ 1modbyaffirm that l have acenificau
mafconsenoref-insuAft
m.oracecateof RECEIPT
Workers'Compensation Insurance or a certified copy,therrof(Sec.31100,late C.)which FTXTI1RES-PER TRAP PARK FEE Y N
covers all employee's under his permit. GAS FA.SYSTEM.ANCA OUTLETS RECEIPTp
Policy# BUILDING DIVISION PC ES
Company GAS-EA.SYSTEM.OVER 4(CA) PLa NCHECK FEE
❑ Certified copy is hereby forehead. (/
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEh
COMPENSATION INSURANCE
(Mir mrian need a.,his,meandered ifthe pemdt is fortune hundred dollats(5 GO) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I verify that in the perfamanew ofthe work for which thin permit is issued,Is hall WATER HF.ATP.R WNEWIELECTR
not employ any person in any manner so ss to become subject to the Workers' PAID
Compensation Lawsof Califomia. Data WATER SYSTEM/fRFATING Dam Receipt#
z Applicant
,�O7Psy � NUNCE'TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDI?NfIAL PLMB. SQ.IT. TOTAL:
!-� V) become.eubjecuo the Worker's Compensation provisions of the Labor Code,you most
�i — forthwith comply with such provisions or this permit shall be dame!revoked. BUILDING FEE 7
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that hem is a convection lending agency for the performance of TOTAL: ELECTRIC FEC +
O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name 0 -4
OPLUMBING WE /F lender's Address QTY. MECHANICAL PERMIT s6
U 1 certify that I have read this application and rate that the above information is
0. correct.In ce in comply with all cit and ordinances and state laws relining to PERMIT ISSUANCE MECHANICAL FEE aS8
gs pdh yon county g b
pj movengrationuctionperlyfri authorize
PurpseemmivaolthiscirytoeateruponNe CONSTRUCTION TAX 6 # S 7
(, z above-me)name pmpenyfor inspection Purposes. ALTER OR ADD TO MECII.
(Wc)agreeti save,indemnify and kap harmlemay
the ay account
CuNairm
liahilitia,judgmcnts,casts and expenses which may in any weyemrveageinst said City AIR HANDLING UNIT(To 10,000 CFM)
ins ace of the gaming of this permit. q5 C
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of ApplicalmCmia car -Dam/uEXHAUST I IOOD(W/DUCT) PAID
HAZARDOUS MATE-RAIZ DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt It
Will the applicant or future building occupant smrc or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: /s
Cade,Section 25531(e)?
0Yes 11 No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will theapplicantorfuture buildingoccupantuseequipmemor Jeviceswhichmat BOILER COMP(3HPOR 100900 BTU)
• havardous air contaminants so defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOLOXI BTU) A dt fisT
Diadcn T- FW 1! fed
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have read the hazWous materials requirements under Chapter 6.95 of the JAN /1 �^^�
California Health&Safey Code.Sections25505,25533 and 25534. 1undemund that 'tl `� yy
jiff tcheb ildingdas not currently have shoed,that itNary rcsponsibilitymnotifythc Gil Y I 'r �u H
occupwt of the requvemenu which must be met prior to issnence of a Cenif cmc of V
cupancy.
Ownaoruuthurizedagent Dam TOTAL: ISSUEDB .
OFFICE