27956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ILDI ICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /N
BUILDING PROJECI'IDENTIFICATION L VJ
BUILDING ADDRESS: SANITARY NO. APP ATIONSUBMHTALDATE
UNITN LOTH ��
OWN[RS NAME: PHONE: CONTRACTOR'S NAM : LIC NO: v
4 NC CONTROLN
RCIIIT'E iiio
LIC NO: ADDH g:
CONTACT: PHONE: ❑
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT LU E
PERMIT ISSUANCE ❑ ❑
LICENSEDCONTRACTORduaerpmvi DECLARATION APPLIANCES-RESIDENTIAL
q yz, Ihercby of Division
amlicenseJ underpmvisionaofCTepmr9(commrncingwith LOB DPSCRI ON
OCau Satiormund ITDivision3.f Ne Business and Professions Code,end my license is in PANELS
z�F Inn tame ane eBeq
QZ Date Clns. OLie.p +G UP TO 200AMP5
F=y Date
CPSGDr F. 201.1000 AMPS
�gyZy ARCHITECI'g DEC ARATION 5/SQ.FT.
Fm p I mcco and my plans shall be used ns public records. OVER 1000 AMPS gQ.FL AREA
QY2Y�1 Lrcrn.tl Prorenusam SIGNS ELECTRICAL.
OC
O� u OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
w
acu- I hereby effrm that I am exempt from the Cantrxcto"License leve for the
nl3Om followingmason.(Section 2031.5,Businessend Professions Codrc
Crain:Any e'ryoounry TEMP.METER OR POLE INST.
11FFF.......(r y which requires a pcmuuo construct,alter,improve,demolish,or repair any structure
r^Qrtuat
� Prior its issrtt,also rcquima the applicant rorsuch permit no file aligned sutement POWER DEVICES
4 qp that he's licensed pursuant to the provisions nfthe Carroulm's License Law,(Chapter
xLp9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_rn mNmheiseaemptthercfmmend the basis for the aIle ed excir tion.An
Y Section T031.5b 6 P Ylpmaon of OUTLETS-SWITCHES-
a, yunydreddollrsaapermit subjats the applicantmacivil peachy of FlXTURES
q t more than five hundred dollars(4500).
W—m ❑ I.mownerofthepmpeny,mmyemploymswiN wagesmthcirsolecompewamon, NEW RFSIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCOON
ty3� wdldathe wurk,and thesuccomeisnot intended oroffered forsele(Sec.2044,Business
and Professions Code:The Contmemr's License Law does not apply m an owner or
propertywhobu'Idsorimproves them.,and whodoes such wm4 himselfoathrough his
howempinyees.progo,i powehimprovemwtsin Oft year
ofCorofrered fofowftf, OCG GROUP HIiS.UNITS
however,theavethe burden of provinum ishathwithinotteyear orcompv (attheowna-
b le.), will have the burden of proving that he did not build or improve fm purpose of TOTAL:
sale.),
❑ 1,mownerortheMNay,amexclusivelycontratingwiNlicensedconhectonto QTY• PLUMBINGPF.RMIT FEE FLOOD zo E ppN
construct the project(Seo.2044,Bminess end Professions Code:)The Can[tucmr'e
License Law docs not apply to an owner ofpropery who builds or improves thereon,and PERMITISSUANCE
whomntmctsfmsuchpmjaHwithacanv tor(s)licensedpursuantmthe ConvacroE
License Law. ALTER-DRAIN&VENT-WATER(PLA) FEE SUM BY
E] 1 em exempt under ga. ,B&P C for this rceaon
BACK FLOW PROTECT.DEVICE UT.
Owner Date SAYR R Y— _
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,�OND. — RECEIPT#
❑ Ihercby nffum that lhaveattnificate ofconscnuo ulfi SCHOOI AS y Iso
nsure.o.Lm
C.)c which
FlXTURES-PER TRAP RECEIPT0
covers kraft aI Insurance orecenifieJ copy thcrcof(SwJgo0,Lvb C.)which PARK E Y__N
Policy All employy5undlthis permit, n 00 GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTN
Company // //((JJlINN �7/ �J BUILDING DIVISION PEEg
❑ Certified copy is hereby fumis , GAS-FA.SYSTEM-OVER 4(BA) M NCHECK FEE
❑ Cmifed copy is fled wi,h,he city impecum.division. GREASKINDUSTRL WASTE INTERCEPTOR
RADINGFEE
CBRTIITCOMPENSATION INSUROMWORKERg' GREASE TRAP
COMPENSATION INSURANCE SOILS FEE
(This section need not be completed ifhe Permit is lbrone hundred dollars($100) SEWER SANITARY-STORM[A.200FT. ENERGY FEE
Or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VF.NT/ELECfR I
Out employ'my tU person m any manner so as to become subject to the Workers /�
Comicant ion Lawa of Califin m. Date WATER SYSTEMnREATWG ID ,j�gb D�—t
z Ger N
�fOi� NOTICHTO APPLICANT:IL after making this CeriOcam of Exemption,you should NEWRESIDFNTIALPI.MB. SQ.PT.
r rn become subject to the Wmker's Compemauon provisions of the Labor Code,you must TOTAL:
•�^ ; forthwith comply with such provisions or this permit shall be deemed revoked. BUIL IN E
UEca CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a Construction lending agency for the Performance of
V O the work for which this Pemtit is issued(Sec.3092,Civ.C.) TOTAL: �'� ELECTRIC FEE
Lmdees Nam
O U e
Lender.Address QTY. MECHANICAL PERMIT FEE PLUMBING ME U O
I certify that 1 have red this application and .in that the above infommioa is J
4 correct-lagrtt 1.comply with all city and roomy ordinance and ante Iowa rtlaring to PERMIT ISSUANCE MECHANICAL FEE
N building construction,and hereby authorize represenadves of Nis city reenter upon the
V Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCfIONTAX
(We)agree to save,indemnify and keep hamdess the City or Cupertino against
liabilities,judgments,costs and expenses which may in any wayuccroe agonstsaid City AIR HANDLING"IT ITO IOp00 CFM)
in consequence of the gmnung of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigmmm of Applicant/Conwctm Dam EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100.000 BTU) Dv¢ ReceiptN
Will the the Cuaotoro ftsm Municipal Code.
Camstorem beaand the
Health ad Sunal I _
as Code,
m the Cupertino Municipal Code,Chap¢r 9.12,and the Hcehh and Safety IIFATING UNIT(OVER 100,0(10BTU) TOTAL: ,Q
Code,Section 25532(e)?
❑Yes 0 N VENTILATION PAN(SINGLE RESID)
Will lhev licanmrfumm buildingoecu ontuse vi _ BOILER-COMP(SHE OR IOOJ100 BTU) ISSUANCE DATE
human...vii mnuminent.vs defined by the Bay Am.plrtQualiry Management
District? BOILER-COMP(OVER H*,0 0BTU)
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.
I have read the hawdous materials naponemetas under Chapter 6.95 of the
California Health&Safety Cade,Section.25505.25533 end 25534.1 understand not
if the building does nm Ommtly have a tort,that it is my responsibility I notify the
cup uirei s whic t be met prior t issuance of v Certificam of UG 31 'g
Oce ancy.
wrier n¢ gem Date TOTAL: ISSUBD By., ..I
OFFICE