27077 PFa"ICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI Y'OF CUP"
'- .I�xTRI PERMIT N°' O
APPLICATION/PERMIT PLUMBING.MECIIANICAL
BUILDING DIVISION BUILDING PROTECT IDENTIFICATION
77
BUILDING ADDRESS / SANITARY NO. APPLICATIONSUB 1TTALDATE
/ J_1 ��— UNIT# LOT 1� {„�
O
'ERS
NAME: PRONE: NTRACTOR'S NAME: LIC NO:
N/C CONTROLM
RCBITECT/ENGINEER: LIC NO: ADDRESS: ❑
ONTACT. PHONE- BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG PLUMB MECH
PERMIT ISSUANCE r ELECT j
LICENSED CONTRACTOR'SMvisiDECLARATION QWzAPPLIANCES-RESIDENTIAL
POO I hereby")ofrmthat l nm lice Business
n ss and isiovoonas Code,
a(commencing with � '•�
+100 fation]00defecivision3of the Rosiness and Profusion Code,and myliceveis in PANELS
W License
ic force and effect.
F,Z GorenuClass Liag UP 20101" MPS D ---
m6y Dete GommfD 201-1000 AMPS
Z z.�' ARCHITECTS DECLARATION OVER Io00 AMPS SQ.FT.FLOOR AREA $/SQ.PT.
O Z—L� I understand my plans shell be used n public records.
<Y � Licensed Promasional SIGNS ELECTRICAL
K OW< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
y U I hereby affirm that I sat exempt from the Cont actoes License law for the
�'
W L O m following reason.(Section 7031.5,Business and Professions Cade:Any city or coumy TEMP.METER OR POLE MST.
rn which requires a permit to construct,altar,improve,demolish,m repair any aavcmre
>� commits issuance,stim,nquires thenpplicaut for such permit to file a signed mammal POWER DEVICES
pp that he is licensed pursuant to the provisions of the Conar m uses License Law Chapter
n o�' 9(commencing with Section700B.(Division Softhe Business and Protections Cade) SWIMMING POOL ELECTRIC VALUATION
h7031.5 by myaefromand the Permit subjeasegedexemptt to Myl persaonof OUTLETS-SWITCHES-FIXTURES I �_
[—. G
Section by any applicant forapermit subjects applicant to penalty mfIre ` (��
^� rat more than live hundred dollars($5W).
CC m ❑ I,asowneroftheprop y,ormyemployeeswiNwagesastheirsmlecompe tion, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONSTHUCI'ION
y�_ willdothework,andtheaructumisno intmddoruffetdfmWe(Sa.7044 us s
and Professions Code:The Contractors License Law does not apply to owner o
properrywhobuilcamimproves thcnon,and whadca such workhimself duoughhis
• ownemployees,pmvidWtatswhimprovemntsmnotintendedorof morale.If, OCC.GROUP RFS.UNITS
however,thebuildingorimpmvemetnismldwithinoneyemofcom etinm,theowner-
builder will have the Wadi of proving that he did not build or i roveforpuryoseof
sal
c .nsowner Il.(Sec.70 1.Business
m tthlic:) cCmanmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
uwm the project(Sec.7(Ld4,Business and Profs na CdeJ The Comrmmr'e pE IT ISSUANCE
License Lawdasnorapplymanownerofpropert bell int tadwaon,and
whtcantmcss former
projects with a con a licensed pursuant to[he Conuanors pLTF. -DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑
Lam
exempt under See. ,B&P C fo ie ninon BACK FL W PROTECT.DEVICE SANITARY OUT Y D N
Owner Deu pRAI S DOR.ROOF.AREA. RECEIPTp
WO MAN COMPENSATION HE
SCHOOLTAX Y N
I hcmby effrmt tlhave eccrtifiate of Lc RECEIPT to xlFin ificam of FIURES-PER TRAP RRCEIPTM
brkers'Compensotion =Mrt thereof(See.3B00, nb CJw ' h PARK FEE Y N
nen all employee's ands is Permit. RECF:I p
Policy# S-EA.SYSTEM-I INC.40l1TLETS BUILDING DIVI IDN .ES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHE.CK FEE
❑ Certified copy is hereby farm d. A
❑ Ccrtifid copy is ftld with the a GRFASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICA'IEOEEXEM ON7.�
RS' GREASETRAP SOILS FEE
COMPENSATION SU
(Thiss.no.need not lsecomphnd ifthe eddollvs($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEEor less.)I certify that in NepMornwce ofthe work fopermit isissued.lsh WATER HEATER WNENT/F.LECTR
of employ any person in any mem so u m nne
erssubject to the W PAID
Compensation Lawsof Califomia. Dae WATER SYSTEMPIRFATING eeeiptN
Z Applicant
Z 2 NOTICE TOAPPLICANT:If,uftermaking this Certificate of Ess ' , oushould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
T—� fy become Subject o the Workers Compensation provisions ofthe Labor Code.you must
�i > forthwith comply with such provision or this permit shall be domed aw kd. BUILDING FEE tea
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hurehY affirm that then is n Consuuction lending agency for the performance of ELECTRIC FF.E
V O the work for which this permit is iuud(See.3097,Civ.C.)
O Under',Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE tA
I amity,that I have and this application sad state Dur the above infmmation is
coram. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingemnsuuaion,and humbyauthonce representatives of this city menterupon the 9
CONSTRUCTION TA
I, Z above-mentioned property for inspation purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hrombus the City of Cupertino against
liabilitieajudgmente,costs and expenses which may in any waymcrueagaimst said City AIR HANDLING UNIT(TO 10,000 CFM)
in /`t^L,eare fthc granting of this Permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
• Signalur�picanU 0 � EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10l BTU) Data Receipt#
Will the applicant or future building occupant am.or handle heudon manriJ HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
• Code.Section 25532(a)T VENTILATION FAN(SINGLE RESIO) 25t
❑Yes No
iSSUA CERATE
Will theapplicanmrfummbuildingoccupant ussequipmentordeviceswhiehemit BOILER-COMP(3HPOR 100,000 BTU)
as air air comtnminu n d andefirby the Bay Arca Air Qu �� wV ality Management BOILER-COMP(OVER 100,000 BTU) y^no
,InaT NEW RESIDENTIAL MECH. SQ.FT.
la •
❑Yea 11 No '
I have red the hmardoos materials ms rinmenta under Chapter 6.95 of the y Ur (,UrClillry(7
I'dfc'aia Ilcahh&Safety Cada Sections 25505,25533 and 25574. I understand Net
if the building does not curently have a mount,that it is my responsibility m notify the occupant of of the requirements which must be met prior to issuance of a Certificate of
Occulxrncy.
Owner m mfirmimd agent Dote ISSUED BY:
OFFICE—
ti
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dse23,
00,
/-i Master Bathroom Project
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