27245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITU'OF BUILDING
PLUMBINGUUILDN -ELECTRICAL PERMIT NO. 27245
BUILDINGc DIVISIONSION sloN APPLICATION/PERMIT -MECHANICAL
BUILDING PROJECT IDENTIFICATION
IIAING ADDRESS: SANITARY NO. APPLICATTON SS/.UBM,IKTTSAL DATE
22.4 22 (...PT r`(V OV l7T I UNIT# LOT# �.1-1 V
OWNERSz1—Lfly NA,MEe LJC.V�� P ONHZ5 ACTOR'S NA / LIC NO:
N/C CONTROL#
�RCHITECT/EN_GINEBR: LIC NO: - ADDRESS: ❑
/i C?S T r o
CGNTACT: PHONE: - BUILDING PERMIT INFO
p o u(5 � f QTY. ELECTRIC PERMIT FEE
7 V BILDO PLUMB EC
PERMIT ISSUANCE �{ El
CONTRACTOR'S DECLARATION pppL1ANCPS-RESIDENTIAL
Qc`z Ihereby affirmthat l am licensed underprovisions of Chapter9(commencing with IOB DESCRIPTION
Poo Section 7000)of Division 3 ofthe Business and Professions Cade,and mylicense is in PANELS
fall FU Licerrceandeffm[. `�- � E
GamZ, License Class Lia# UP TO YOO AMPS H
rn 7 y Dme Conuactor 201-1000 AMPS
O8`.n Z4, ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $ISQ:FT.
I understand my plans shall be used a9 public records.
Q��1 Licensed Professional
NSIGNg ELECTRICAL
FJ N -
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 1•
t F I hereby affirm that I am exempt from the Conuaetoes License Law for the
W m following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEM.METER OR POLE MST,
E 3O which requires a Permit m construct,alter,improve,demolish,or repair any sweture
pWray Prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
yI�5 O p that he is licensed pursuant to the Provisions of the Contracmis License Use(Chapter
a p,ow 9(commencing with Suction]")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
y(_,y or h70315 by exempt mtherefrom and the ba.its bjthe
ct.alleged exemption.Any violation of O • /A ,,.a���
G Sedion]03 LS by any applicant fora permit eubjedathe epplicannoecivilpendry of DDTLETS,$WITGHFS-FIXTURES Lis a�jJ( C[V
not mare than five hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ.PT.
H. ❑.Lasowrk,and'property,ormyemployeol.feegesasthei(sole c0mpem mess STORIES TYPE CONSTRUCTION
L will dotbcwons and rhes o Contractor's
intended sicse ofw ed does not applyrame t an Business
and Professions Cade:The Contractors License Law deer r apply lf am owner of
' ..
property whobuilds 0rimproves thereon,and whodoes each workhimselforNroughhis
own empinye.,pmsided Nmsuchimprovemen[earemotintendedorofferedforsaleIf, - OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
le TY. PLUMBING PERMIT
I,as owner project
(Sec.70 4.Business
=it Professions
s Clic,.)sed To,Comctotsto Q PEE FLOOD ZONE ApN
I con ct the project(Sec.]044,Business and Professions or arp The Contracwr'e
who commove,
ewdmsnohproj manow.cmimaoperty who buddsadtnproves Hereon,and EMIT ISSUANCE
whence Lamsforsuchprojems witb econrcamor(s)licenced pursoan[mthe COnuecmr's
License Law. AL -DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ lam exempt under Sec. B&P C for this ices BACK W PROTECT.DEVICE OUTSIDEES
SANITARY Y N
Owner Dat° DRAINS (30R,ROOF,AREA,COND. RECEIPT#
' WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ih Cmaperereby nmlausithat I aveaceni to a ceateofconse therof(St to Self nsure, certificate of FIXTURES TRAP REC #
Worker%Cmployer'ionler this ermit. ifW copy thereof(Se ,Lab C.)which PARK FEE Y N
resit employee's under this permit .SYS -1 INC. 0UTLETS REC PT#
Policy# % BUILDING DIV ION FEES
Company - AS-LA.SYS OVER4 EA
❑ Certified copy is hereby famished ( ) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GRFi1SF,/1 STRL WASTE INTERCEPTOR GRADING PEE
0 f36 oafs
/�a I.
CERTTFICATEOFEXEMPDON FROM WORKER 5 GR ETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundredd ars($100) EWER-SANITARY-STORM EA.20 ENERGY FEE
reby a'
cutlass.)
I certify that inthe Performance of
work for which this permit is issue Ishall WATER HEATER W/V
not employ any person in any meaner se as to become subject m the Wo a PAID
zCompensation Luwsof California. Date WATER YS IN 1 pate Receipt
Applicant '
O NOTICE TO APPLICANT:If,after making this Certificate,of Exemption,you should E R Fr TOTAL:
In become subject to the Workers Compensation provisions otthe Labor Cada yodrisus.
Forthwith comply with sucM1 provisioru m this permit shall be rimmed rooked, d, BUILDING
�+
pW,a Q CONSTRUCTION LENDING AGENCY SETS
I hereby affirm that there is s consumed..leading agency for the perfotmaaee of
r U O the work for which this permit is issued(Sm.309],Civ.CJ Q I TOTAL: ELE EE
C) ULenders Name
Lender's AddressQTY,,#., MECHANICAL PERMIT AEE PLUMBING FEB
LTI I certify that I have read this application and state that the above information is MECHANICAL FEE
correct lagan tocomply with all city andemartyordireaneesaod stimlawinchongto PERMIT ISSUANCE
y building construction,and hereby amNorize representatives of Ms city to enter upon the
U z above-mentioned pre for inspection purposes. ALTER OR ADD TO MECH. ' CONSTRUCTION TIX
(We a to indemnify and keep harmless the City of Calandra against
liabilitie. judg a andexpereseswNchmaymanywayaccm dna[ id Ciry IR HANDLING UNIT(TO IO,gq CEM)
in s of r[/./
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature V
pplicano'Contrador Dale EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt# -
Wil
l he applicant or future building occupant store Or handle hazardous material
t m define by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Seedim 25532(a)]
❑Yes 0N VENTILATION FAN(SINGLE RESID)
ISSUANCaM - E
Will theapplicantorfulumbuildingaccupunt useeqvipmentordevices which emit BOILER-COMP(3HPOR NXLpX)BTU) - P ®
Mous 11 Yes
air contaminants se,defined by the Bay Area Air Quality Management BOILER-COW(OVER US),"BTU)
��
o
Yes No _ NEW RESIDENTIAL MECIL' SQ.ET. /1
I have read the hazordous materials requirements under Chapter 6.95 of the 4 .Ve '/`I 1999.S`
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does no[meats ly have a must
tanq thato is my responsibility to notify the
occupant of the requirements which must be met prior m issuance of a Certificate of
Occupancy.
Owner or authorized agent Dale
ISSUED BYWV� •//
OFFICE