27561 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IHIR:DINT.�'EPC77HCd• PERMHNO.
APPLICATION/PERMIT PLUMB[NG-MECHAN]CAL
BUILDING DIVISIONBUILDING PROJECT IDENI'IF'ICATION 27561
BUILDINGAADDDRI35S: �/ / �/A' SANITARY NO. APPLICATION SUBMI'1.1'AL DATE
!J✓RI /�,I`� / I UNIT# LOTavnwl
Ow AME: P ONE: /�+''l ('CONTRAC "NAM[: / LICNO:
/ tlN ee o LT—, . b - f N O// IV Yj7 f N/C CONT OLp
.ARCHITE ANGINEER: LICNO: ADDRESS: ��A /Jto
SOo5•W/mc,6S`kF ,S � S
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDI G PERMIT INFO
j3LDj'i ELECT' 1'LUppB ME
PERMIT ISSUANCE - 1LDQ ELT. T ^']lyU]�•'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
004Z I hereby affirm that l am licensed underprovisions ofChaptm9 ponunencingwith TOB DLSCRIPf1cars
❑10µ101�. Section 7")of Di isio Sof the Business and Professions Code,and my license is in PANELS '
Iy V V full force and cffwL p '/C/ e-����
2z p4 License Class Lic.p 37a 17 / IIP T0200 AMPS `Js~�1Y)
�T Dat, Coutimun 201-I"AMPS
Z0,—, ARCHITECTS DECLARATION OVC0.1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
O Z,❑ I understand my plans shall be usM as public records.
QL4 SIGNS ELECTRICAL
y V Licensed Professional LLL///KKKTYY JJJ
Sya< OWNER-BUILD GRDECLARATION SPECIAL CIRCUR/MISC.
C
iaO eUc� 1 hemby of0nn that I ER exempt from the Contractors License Law for the - I
W 3 0.N following reason.(Salon 7031.5,Business add Professions Cade:Any city or caunry TEMP.METER OR POLE INST.
f'
is
requires a permit to constmn,alcor,improve,demolish.m repair any swdum
Kn}n prior to its issuance,also requires the applicant forsuch permit to file a signed statement POWER DEVICES
to K G O that he is licensed pursuant to the Provisions of the Contractees I.a...Law(Chapter
0. 9(commencin with Section 7000 I'Divism 3ofthe Business and Pmfessioaa Code SWIMMING POOL ELECTRIC aa,
gwi to ) VALUATION `/•4%T
W.may mNrd ion 7031.5 by tbercfmmadd the basic"m'be afieliml sflo,iexemption.Any violnion of OUTLETS-SWITCHES-FIXTURES 41 7>8
�ZQ Section 7031.5 five
any opplicollarsnt for.$500). suhjecu tM1e appli<anuoacivilperat"of
�0 not.,,.,ban five hundred dollen(5500). NEW RESIDENTIAL ELECIR 5 .PT.
m ❑ oche work,
epropmy.ormyemployed or ofwagnasalei(sole compemetial, STORIES TYP ONSTRUCIION
It; will dothewons Carlo a Contrsnot intended License
Law
for s,not apply in an Business
and Professions Code:The Contractor',License law does not apply to an owner of
properly who builds or improves thereon,end who aces such work himself or through his
nemplthees,providedtprove ant is setnenuarenoiearofdmoffcred threats. (. OCC.GROUP RES.UNITS
h il cgillhav l the burden
ofpmedtissat he di in 1Imildafcomple for the owner
builder will have the burden of proving Net he did tws build or improve far purpose of
sole.).
❑ Lasownerofthepmpeny.umexdusivelycontnningwith licrnsed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONI3 APN
Lmand,the prnjen(Sec.]M4,Business and Professions Cale:)The Comeactres
icenulawdmanot applym anownerofpropmy who buildsorimpmves thereon,and PERMIT ISSUANCE
who contracts forsuch projects with acontraamt(s)licensed pursuant to the Cradmicto's
License law. ALTER-DRAIN Al VENT-WATER(HA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis(mean BACK PLOW PROTECT,DEVICE SANITARYY D E
—N—
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION ❑ INS-FLOOR,ROOF.AREA,COND. SCHOOLTAX Y—N—
I hereb
Ihereby all.thin l have acenifcate almost toself-imme, acertiftca f 1 ES PER TRAP RF.CHIPT#
Wnrkcn'Cnmpensetinn lnsaranceornc<rtified copy thereof(Sec.3B Lab PARK FEE YN
covers all employee's under this permit GAS-BA.SYSTEM.)INC.4 OUTLET-
REC131PT p
Policy M - BUILDING DIVISION FEES
Company ,CarCcniOeJ copy is hereby famished. v 8
❑ GAS-HA.SYSTHM-OVER4 EA) PLANCHECK FEE
❑ Cenified copy is filed with the city inspection division. GREASFANDUSTRLWASTEIN TOR GRADING FEE
CERTIFICATE Oil EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE �r
COMPENSATION INSURANCE
(Thissectionneednotbecomplcv ifthepemtitis foronehundrWdi lass(51(10) SEWER-SANITARY-STOR 200FT ENERGY FEE.
or less.)
Ittnify that intheperfrrmanceofthe work forwhich thispemtit isisaued,l shall WATER HPATER WN[iNT 'L, R
not employ my person in any manner an as to become subject to the Workeri PAID
CanmmmiEErn Lawsof C.lifamia. Date WATER SYSTE T G Date R cipt#
O O NOTICtTO APPLICANT:If,after makingthis Certificate of Exemption, o should NEW RF.SIDENI'1ALP 5 Fr.
Yu Q.
F" y become subjectaply it Workds Compensation Provisions
rmitio shall
Labor locked. must TOTAL:
'-•t forthwith comply with such provisions or this permit shell he deemed rcvakW. BUILDIN #tea
OWa [] CONSTRUCUON LENDING AGENCY SE F, o
Vz 1 hereby affirm Nat shote is,sued(Sm.3 lending agency for the performance of
Q the work for which this permit is issued(Sec.309],Civ.CJ GL: FEF
U.
Cordels Name PLO G FEE
0 U Lender's Address QTY. MECHANICAL PERMIT FEE.
I certify that 1 have read this application and stele that the idrove information is
anrect.l agrx to comply with all city and money ordinummar and state laws relating to PERMIT ISSUANCE CHANICAI.FEE
building construction,and hereby hidimiae repolonmtivesofthis city to enter upon the
above-mentioned C.a SIRUC IONTAx
[� 7 properly for inspection purposes. ALTER OR ADD TO MECH.
r7 (We)agree lo, indemnify unJ keep hunnless the City of Calendar against
liabilitiesac coatsandexprns which eccrve ainat ,City AIR HANDLING UNIT(TO Ig000 CPM)
.1a nse ue the grumhrg.a[
3 / 94x" AIR HANDLING UNIT(OVER 10,(#q CFM)
J
gnamre ofApplicenl/CoDm EXHAUSTHOODW/DUCTI t
PAID
HA2,WOUS MATERIALS DISCLOSURE HEATING UNIT(O 1011,000 BTU) Dat Receipt#
Will the applicant or future building occupant store or handle hicommus mmerial HEATING UNIT(OVER IOD,00013'I'U) TOTAL:
as defined by the Cupen ino Municipal Cole,Chapter 9.12,and the I lealth and Safety
Cole,Section 25532(a)T
11 Yes 13 No VENTILATION PAN(SINGLE RESID)
Will the uconta contaminants
building by the
nBay Area Air
eswhich emit
BOILER-COMP(3HP OR 100,01)BTU) ISSUANCE DATE
hazardous air contaminmts m defined by the Bey Area Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU) Iy0
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P -p K D
1 have read the hazardous materials requirements under Chapter 6.95 of the ty//I D �#
Cauldrons Health&Safety Cada Sections 255D5,25533 and 25534. l i ndersund Nm x'1(11? d 19t1p.
atmonat of
he esnntcunts which
he thing is myreuanceofitymnotlate of C//� /s7lJ
occupant of the requiremema which must be met prior to issuance of a Certificate of (f
oaaapamy.
Owner m uuthmaved.,cut 'TO ISSUEDB lN(J