27430 „APPL II ANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
R ILD .-ELECTRICAL PERMIT NO, 0
CI BU OF CUPESIO NO APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDkl355: ��x11 )) rJ sr-) SANITARY NO, APPLICATION SUBMITTAL DATE
'� GO Wiiy6F.R. fZ Us UNIT» LOT#
OWNERS NAME "'ONE w\ "HONE: CONTRACTOR'S NAM;_' �L,NO �C
Sr Lie VL NfC CONTROL”
CHITECT/ENGINBBR: LICNO: AD RESS: ❑
CONTACT: PHONE: I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE L ELECT PLUMB MECH
1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL D
pty.,z Therebyaffirm that lionicensedunderprovisions of Chaptir9(commercial,with JOB DESCRIPTION
ti100❑ Sedio.andof Division 3of the Business and Professions Code,and my license is in PANELS
<Z, Licfailense
nse Cladeffece UP TO 200 AMPS
F Z W License Class Con#
h=y Date Contractor 201-1000 AMPS
ZOyz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA - S/SQ.FT.
O Z^q I undcrsmnd my plans shall be used as public records.
r4 W SIGNS ELECTRICAL
� .I LrcensedProfesvonal
C ¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ixpy.SO C:V I hereby affirm that I am exempt from the Contractor's License Law for the
41B WON following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLEINST.
m.¢J which requires a Permit to emstmm,alter,improve,demolish,or repair any sweture
��Y� Prior to its issuance,also requires the applicant For such Permit o file a signed sentiment POWER DEVICES
ay that he is licensed pursuant to the Provisions of the Contmendex License Law(Chapter
iCca 90wmmenclog with Section7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES- s�V
Section 7031.5 by any applicant for a permit subjects the applicant m.civil penalty of FIXTURES /� '1 //��
�F� of mom than Five hundred dollars($500). ,4 2,V
❑ I,usownerdlrheprnperty,drmyemployeeawitb wagesee Heirsolecompereetion, NEW RESIDENTIAL FLECfR _SQ.FT. ST RIES TYPECONSTRUCTION
a3— will do the work,and the structure is not intended murdered for sale(Sec.J(14q Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves Hereon,and who does such work hinead f or through his
own employees,provided that such improvements are not in,,ndedoroffered Tarsale.If, OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofeempletion,theowner-
builder will have the burden of proving that he did not build or improve for pmpose of TOTAL:
said.).
❑ I,asowner ofthepropeny,amexclusively contracting with licensedcontranors to QTY. PLUMBING PERMIT FEE FLOOD ZONE 11N
o istruct the Project(Sec.7044,Business and Professions Code:)The Correctors
License Law does not apply in an ovarImpropeny who build,or improves thereon,and PERMIT ISSUANCE
who contacts For such projects with.coundro Ks)Iioensedpuesuamm the Contractors ALTER Law. WATER(EA) FEE SUMMARY
❑ 1 can exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEV OUT I FEPS
SANITARY Y N
Owner Dati DRAINS-FLOOR F,ARGA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby affirm that I have a candidate of consent m self-insure,or a certificate of RECEIPT#
dods'Compensaden Insurance or a certified copy thereof(Sec.3800,Lab C.)which Fl -PER TRAP PARK FEE Y N
Pavers ell employee's under His permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ Cmified copy ie herehy Pomished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP FE
SOILS E
COMPENSATION INSURANCE
(This section need not be complemd if th<pumit is fomne hundred dollars(SI ) SEWESANITARY- AOFT.
R- . GY FEE
or less)
I certify that in the perfirmenna of the work for which this permitis issied,1A i WAT HEATER E ECTR
not employ any parson in any manner so as he become subject m the Worke ppI
0 Z Compensation Laws of Califomia. Date- WATE S EATING Date Receipt#
Applicant
z .0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW NTIALP SQ,IT. TOTAL:
C. became subject to the Worker's Compensation provisions of the Labor Code,you must
7 forthwith comply with such Provisions or this permit shell be deemed revoked. IsBUILDING FEE
pW, z CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there is a concoction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
w (r Leader'a Name
U Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and state that He above information is MECHANICAL FEE
W counsel.I agree m comply with all city and county ordinance teal state laws relating to PERMIT ISSUANCE
y building construction,and hereby authorize representatives ofthis city to enter upon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilidwi.judgmeem,costs end expenses which mayinany wa eremeagainst said City AIR HANDLING UNIT(TO 10,000,CFM)
In co of the g ting of Is
AIR HANDLING UNIT(OVER 10,000 CFM)
rgnawrc fApplicam/Contr for ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10X1,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle haamdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(.)4
❑Yes 0N VENTILATION FAN(SINGLE REBID)
Will HemPPlicanmrfumre buildin oecu ant ueegvipmen[ordeviaea which<mit BOILER-COME 3{p OR 100,000 BTU)
ISSUANCE DATE
I
70om,rwy.
ir contaminants es defined by the Bay Area Air Quality ManagementBOILER-COMP(OVER 100,000 BTU)knotY ❑Y. ❑No NEW RESIDENTIAL MECH. SQtie �g,.�I ave read the hazardous materials requirements under Chapter 6.95 of the �a l/�baa h%I1995
lifomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand thathe building does not currently have a tenant.that it is my responsibility to notify theVLcupant of the requirements which must be met prior to issuance of a Certificate of t t{I IN
mermauthomad.gem Date TOTAL: ISSUED BY:
OFFICE