27034APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OECUPERTINO B ILDI x-ELEUJKICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-MECHANICAL.
BUILDING PIIOdEC1' IDEN'TI FICA9'ION
PERMIT NO.
O 34
BUILDI
G/VA7/1DDRF.SS: /y—/
I -7'1/ baba UNIT# LOT#
SANITARY NO.
APPLICATION SUBMIT/TTAL OATS
eV
93
OWNERS K I „. l_ /. PIIONE: _ /l�
/N17`
LJX'At`J
ONTRACTOR'S F }' of
N/C
❑
CONTROL#
ARCHITECT/ENGINEER: LIC NO:
ADD.
CONTAC/j PHONE:
IIIf
QTY. ELECTRIC PERMIT (.'EE
BUILDING PERMIT INFO
BLDG LE PLUMB MEC
PERMIT ISSUANCE
/II/�1✓Ah 1� lI YY
LICENSED NTRACTOR'S DECLARATION
mmenei newish
1 hereby aBirmthat I stn licensed under nd prof
of Chapter9 sand
Section a orad of D' 3 of the Rosiness end ProfLe.s�'ions Cycle end my licensers in
,allforce and effe ..,n , / —
APPLIANCES -RESIDENTIAL
JOB DESC IPTION
'/yI fa yI
iI Vy yI V 'I- C
PANELS
V
License Class Lic.# VV (,(/
UP 0200 AMPS
Date Contractor
201 - 1000 AMPS
ARCHITECT'S D
I understand my plans shall be used m public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL.
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt from the CarrLicense Law for the
TEMP. METER OR POLE INST.
Co city or county
Professionsh,,
which ingreasoa. (Section 7031.5, Business seen,i
which permit re teas ic,ny
alter, improve, demolish m repair any structure
pr
its is n the smmment
statement
prior its also requires thevisio
forstichCo
FOWER DEVICES
s dition's License La
of the Contractors License Law (Chaplet
that 1¢ is licensed with Sectio to the) of Division
Division Sof the Business and Professions Code)
ocommorming ixemitM1erefro and the
or h7031.5 by any refromand the Permit subjects thedexemant to Any civil penalty of
Section by Permit subjects the applicant [o ecivil penally of
SWIMMING POOL ELECTRIC
VALUATION
'Jf
/ 2� Cj /
OUTLETS -SWITCHES -FIXTURES'
undre doltfora
not hundred
t mom than Rvethepmddollurmyem)_
n❑Lthewnerof[hepraperry,urmyemployediamfiwagesnsilei(sole cumpensa[ioa.
NEWRESIDENTIALELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
will do Newark, and the she amouCoul stot is 7044. Business
and Professions Code : The C La downed
License not
License Lew does not apply lf at owner of
ply
s thefcm,
propertywyees, pdsorimproves[hemot,nndwhodoessuchwmk himeexedficoughhisown
employees,not for sale.If,
impis
OCC.GROUP
RES. UNITS
TOTAL:
gorirovided proveat
sold itature
hinonehtenfcomplfered
however,thehave
building hu improvement of proving that
et budid or comm¢ for the purpose
he did of
hales). will have the burden of proving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
Iv.).
❑ Las ownerof the pmpeny,amexclusively, contracting with licensed contractors to
FLOOD ZONE
APN
construct the proved (Sec. 7044, Business and Professions Code:) The Cottmamr'e
License Law does not apply to an owner of property who builds or improves thereat, and
PERMIT ISSUANCE
who contracts for such projects with a comradons) licensed pursuant to the Contmchas
License Law.
ALTER A
FEE SUMMARY
❑ 1 em exrntpt under Sec. , B & P C for This reason
BACK FLOW PROTECT. DEVICE
OUTSID FE
SANITARY RECEIPT# N
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
EI Ihercby affirm thutlhaveacenificadeof consent to selGinsure, orattni0cate of
Workm' Compensation lnsu n< o certifieda PY therS (Sec. 3800, Lab C.) which
SCHOOLTAX YN—
RECEIPTs
FTXTURI?S - PER TRAP
PARK FEE Y N
mall employee'sm 6?
Poli"# L
RECEIPT
GAS - EA. SYSTEM- TLETS
BUILDING DIVISION FEES
Compamt
❑ rtified copy is hereby fun
GAS -FiAlS T -OV
PLANCHECK FEE
IsGAEASL EINT>FRCEPTOR
GRADING FEE
Certified copy is (cited withthe city inspection division
CHR'fIFICATE OF COMPENSATION INSURANCE WORKERS'
SURA E
C
(This section need not be, completed lfthe permit is forom hundred dollar,bold
orless.)
I certify that in the pofomunce of the work for which thispenzit is issuad. (shall'
�REAS�E
SOILS FEE
\ 9FWER-SAT RM EA. 200P1'.
I IQ
ENERGY FEE
W .R WNENT/ELECI'R
not employ wayperson in any manner an as to become subject to the Workers'
Campasmionlmwsof Califomia. Date
PAID
Data Receipt#
`h'WA R SYSTEMORFATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, youTas[
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affum that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Name
TOTAL:
ELECTRIC FEE
Lendoea Address
QTY. MECHANICAL PERMIT FEE
PLUMBING ME
I cenify that 1 have read this application and state that the above information is
enact. l it,mem comply ith all city and county oninancesand smm,wsrelatitg to
PERMIT ISSUANCE
MECHANICAL FEE
huildingeonsnumion, by authorize represematives of chis city roamer upon the
above-mentioned pro e f insp tion purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree dos v n' and keep harmless the City of Cupertino against
liabilities,judgments c e martwhichmnymanywayacemang 'ants dCity
AIR HANDLING UNIT TO 10,01)(ICFM)
In onseyuenw oT th g n o tis rsmlc
AIR HANDLING UNIT (OVER 10d" CFM)
Signature of Applicant/Contractor Dr
EXHAUST HOOD (W/DUC D
PAID
T. HEATING UNIT (TO 100,04(g) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dace Receipt#
Will the applicant or future building occupant store or handle hazardous material
as detriment by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
IOTA
VENTILATION FAN (SINGLE RESID)
(ATE
Code. Section 25532(u)P
❑
11 Yes No
Will theapplicatorfuturclandeing occupoduse equlpmemordeviceswhich emit
ISU
BOILER- COMP (311P OR 100,000 BTU)
BOILER - COMP(OVER 100,000U)
BT
lactation, air conmminants es defined by the Bay Arca Air Quality Management
District?
07 1995
❑ Yes ❑ No
AUG
NEW RESIDENTIAL MECH. SQ. FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
b
California Health & Safety Code, i ns 25505, 25533 and 25534. 1 understand that
J 1 U% r wrtr+l
ifdhe building does not currently av atenant,that it is my responsibility m notify the
occupant of the requimmenrs Wvoh O lb, met prim to isat ee of a CeniOcam of
Occupancy. /Y
ISSUED BY:
Owner or authorized ager Date
TOTAL: t
OFFICE