27802 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
d—CITYaOF CUPENO IIUI,BIK(iN',E,' O' A. ' PERMI"T NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECI'[PEN]'IF[CALION -a
2-7802
BUILDING ADDRESS: ` `Q n� SANITARY NO. APPLLIICA'I]ON SUBMETAL DA 117.
(• Fp�-O% \J`/W)/S6UND# LUT#
OWNERI! �ct P�yI� X1/1 �1- CONTRACTOR'S NAME: v(�,C�, 1a-1,IC N0:p�•�,.r NAZ ✓ CONTROL#
AROUECr/ENGINHER: ELIC NO: 1VT{O ADDRESS: SS EIZVE..7MLYJSCs('A /Jf CONTACT: PHONE:PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMITISSUANCE ❑ - ID ❑ �1
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIALL�
p 7 1 herebyaffinn Thal I rem licensed underpmvisiomof Chaptc,9(commencingwith JOB DESCRIPTION
BJOOG Section9000)of Division 3ofthe Business and Professions Cade.and my license is in PANELS
a W U mu License
ma enter. / p �' M„ ,,,,� - ^
<Zu1 Liccnx Clas¢'Ja'C`:D C=j'Lic.p c;?224[j50 UP T021q AMPS [ �.J�LQ.J¢jQ.i,J�-
N Q d Dae Canmmor 201-I"AMPS
F-y% ARCHITEC'T'S DECLARATION OVER IINIO AMPS SQ.FT.FLOOR AREA S/SQ,IT.
ZO
O_Z—yr a I understand my plans shall bar used as Public mcotds.
�
SIGNS ELECTRICAL
gFqNf, Licensed Professional
E:WeZQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
dOyu L hereby affirm that T on exempt from the Contractor's License Law for the
WxguvF followingreresna(Section 9031.5.Business and Pmfessinns Code:Any city or couny TEMP.METER OR POLE INST.
F-a O which mqulres a Permit to construct.alar.improve,demolish,or repair any suvaum
$yty}5 pri�rm its issuance,also requires the applicmtlm sucM1 permiuo Tileasigned sm¢meot POWER DEVICES
W <O that be is licensed pursuant to the provisions of the Contractor's License Law(Chapter
p SWIMMING POOL ELECTRIC
sx "' 9(commencing with 3refrom0W)of Division 3ofthe,d Business end Profession Code) VALUATION
,noo or that he Ls estuaries therefrom and the basis for the alleged exemption.Any violation of
FZa Section 90315 by any applicant fur a permit subjects the applicunuo a civil penalty of OITILIiTS-SWITCIIliS-FIXTURES
5E< not more than five hundred dollas,(S500).
x tzCi ❑ Lasownerofthe property.ormyereployeeswith wages as theirsolecompereation, NEW RESIDFNTIAI.ELF:CTR SQ.FT. STORIES TYPE CONSTRUCTION
y3!2 will do the work,and the slmnum is not lmcndcdoroffercd for sale(See. Business
and Professions Code The Contractors License Law docs not apply to an Owner Of
prolwrty who mild,a,impmmes thorcon,and whodoex s.ch work himmlfonhmvghhis
ownemployecs.pmvideddist corniest, .ntearenotirmadedorofferedforsale.If, OCC.GROUP RIES.UNITS
however,the building or improvement is sold within one yearofcompletion,theawner- TOTAL
builder will have the burden of proving as be did not build ur improve for parFosc of
vale')' QTY. PLUMBING PERMIT E FLOOD ZONL APN
E] L as owrcrafthc property,v exclusively contracting with licensed contractors to
construct the project(Sec.70414,Business and Professions Code.)The Contractor's
LicenmhwdocsnmaMlymmownerofpropenywhobuii&orimprovestM1ercon,and PERMIT ISSUANCE
whocomracts for such Projects with acontrecto bd licensed pursuant to the Contractor's
Liccme Law, ALTIER-DRAIN&VENT-WATER(Ei FEE SUMMARY
❑ 1 an exempt under Sas ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE UI'.IDE FEES
SAN A YN
Owner Date DRAINS-FLUOR.ROOF,AREA.COND. RECF,IFF#
WORKMAN COMPENSATION DECLARATION 1 L'TAX Y N
❑ Ihcmhy affirm that✓haves certincure of con.m mselGinwrt,mnccnificvm of FlXTURES-PER TRAY RECEIPT#
Workers'ComPeuastion Insurance or a certified copy mernof(Sa.3800,Lab C.)which PA Y N
rs
coveall employ.'.under this permit. GAS-EA.SYSTEM.I INC.4 OIJTLM- RECEIPT p
Policy# .DING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHI!CK F
❑ Ccnificd copy is hereby famished.
❑ Cenitinl copy 1.filed with the city impection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOLES IEE
COMPENSATION INSURANCE.
m
(11issectivarsool be completed if Ne permit is furore hundred dolars(E100) SEWER-SANITARY-STORM EA.20s ENERGY FEE
or less.)
I crony that In the performance ofthe work fur which this pcmtit is issued,l shall WATER HEATER WNENT.LECTR
not employ my person in my manner so as to become subject to the Workers' PAID
Compensation Laws of California. Date WATER SYSTEM/REiATING Dam Receipt
zz Applicant
O NO'T'ICE TO APPLICANT':If,after makingthis Certificate Of Exemption.you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
p ,g, become subject to the Workcrx Compensation prous
visions ofthe labor Code,you must forthwith PEE
� ? forthwith comply with.such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z T hereby affirm that them is a construction lending agency for the perfutmm<c of TOTAL: ELECTRIC ItiE
U O the wink for which this permit is issued(sec.3097,civ.C.)
Lender's Nis r PLUMBING 17EE
F Lender's Address QTY. MECHANICAL PERMIT FEF.
V I cenify that I have mad this application and stain than the above information is MECHANICAL FEE /a
T Lk1 career l agree to comply with all city and county urdinancesund Stam lawsrelatingto PERMITISSUANCE
I-" buildingconsimction.mdherebyauthorinmpm,enative,of NiscitytoenmruWnNe CONSTRUCTION TAX
Valssve-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to nave,indemnify and keep harmless the C'ny of Cupertino again.
Iiabiliti.judgmenes.costsmd expenses which may inmy way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
an,ce uenee of the 6mming of Thi- it.
3/io 9T AIR IIANDLINOUNIT(OVER IO.IXNICFM)
Si stare of Appliem tactor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I W."BTU) JQLe Receipt#
Will the applicant or future building Occupant store or handle M1mnrdous material TOTAL
ii
as defined by the Cupertino Municipal Ccdc,Chapter 9.12,and the Heath and Safety HEATING UNIT(OVER lIX1,IX10 BTU)
Code.Section 25532(87 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No C YCO )as/1$$UANCE DATE
Will the applicamorfumrt building Occupmtuse equipmentardeviceswhichemit BOILF,R-COMP(3HPOR RXI,WOBTU) (/r.
dour air conminaA.tants is defined by the Bay AAir Quality Mmamomin BOILER.COMP(OVER 100,00iLLN�� 9,S
Brief, //ALO
❑Yes ❑No NEW RESIDENTIAL MECt{, SQ.FT. ,Y
1 have read the hamrdaus anile ials ramitemcnv under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I undersand that
tribe building docs not currently have a tenant.that it is my responsibility no notify the
o.opont of the requirtmems which must be met prim to icsumce of a Certificate of
Occupancy. /#
Owner or authorized agent Data ISSUED BY: ���/// 111///"'✓✓✓ ��`
OFFICE