27532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27532_
RUILDIN(i PR(3JEC1'IDENTIFICATION
BUILDING ADDRESS: +,`r L�/C �J SANITARY NO. APPLICATIONSUBMITTALDATE
10161 11 4( ✓ 4677, UNIT# LOT It 2 r S
OWNLRS MF.: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
M a Ihr� EO ooN aFC�Cba�i I
RCHITECT/EEER: LIC NO: ADDRESS:
R �� IZ52. CURT% AJE 5.1 CA 95125 ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
n�^} BLDG ELECT PLUMB MECH
ARIA L -253--7(6Z-,?, PERMIT ISSUANCE El 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �q BD CRIPfION
QWz Iherebyaffirmtha[lamlicensedmak,rovismiruixChapori)metronome,with xTJyTAtt YZ &Ns LIIJE
00 Section 7"1 of Division 3 of the Business and Professions Code,and my license is in PANELS
q.UF full force and if, I / pe
4F,Z WVjy License 11.... le Lic.p�' I D —�y UPT0200 AMPS GAS �� �l'�
y 6 y pate Contra c�Qlo 201-1000 AMPS
zONZ ARCHITECT'S DECLARATION SQ.PT.FLOOR AREA $/SQ.FT.
OVER 1000 AMPS
O2—p I mndersmnd mIf1p�la�s shall be usetl as public records.
Licensed Professionnalal Q SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�yaa(4
OF 4a U 1 hereby affirm that I an exempt from the Contractors License Law for the
00'3 q0 ti following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
m y which requires a Permit to construct,alter,improve,demolish,or repair any structure,D+ prior to its issuance,also requires the applicant for such prrom to file a signed statement POWER DEVICES
pp that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
q o�s 9(commencing with 5ecdmu7000)of Division 3o1fthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exemprtherefrom and the basis for the alleged exemption.Any violation of -
Q Section 7031.5 by any applicant for a Permit subjects the applicant a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500).
�(;ca ❑ I,asowneroftheproperty,mmyemployeeswithwagesastheirsolee mpensa[ion, NEWRESIDENTIALELLCTR _SQ.FT. STORIES TYPECONSTRUCTION
q3-- will do the work,amd the suucmre isnot imendelm,iffewd forsele(Sec.7044.Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselforthrough his OCC GROUP RES UNITS
own employees,poev ided that s uch improvements are not intended or offered hermit.If,
however,the baildingor improvement is sold within one yearofcompletion,theowner- TO
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepmpeny,amexclusivelycmvactingwithlicensedcommctorsto QTY, PLUMBING PERMIT FLOODZONE APN
construct the project(Sec,AViq Business and Professions Code,)The Contractor's
License Lawdoesnot apply man ownerofpropeny whobmlds orimpeaves themon,anJ L PERMIT ISSUANCE
whocounins for such projects withacmnractorls)licensed pursuant rothe Contractor's ALTER-DRAIN&VENT-WA R(EA
Lloense Law. ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason $
BACK PLOW PROTECT.DEV/E ITARY Y N
Owner Date DRAINS-FLOOR,ROOF, EA,CONI RECEIPT#
WORKMAN COMPENSATION DECLARATION SC OOL TAX YN
EII hereby affirm that l have a certificate ofconsem t0 self-insurc.ora cerfificatenf FIXTURES-PERTRAP RECEIPT#
Workers'Compensation Insurance or ecenifed copy thereof(Sec.380,Lab CJ which P RK PEE Y N
covers all employee's under this permit' t CAS-EA.SYSTEM-11 C.40I1TLETS RECEIPT#
Policy# BUIL NO DIVISION FEES
Company GAS-EA.SYSTEM/VER PLANCHECK FEE
❑ Candied copy is hereby famished.
❑ Cmified copy is bled with the city inspection division. GREASUNDUSYL WASTE INTERCE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe Permit is boroae hundraddollars($10B SEWER-S ITARY-STORMEA. ENERGY FEE
m has,)
I certify that in the perfotmance of the work for which lhispermit is issued,lshall WATER EATERW[VENT/ELEOW
not employ any person in any manner so ay.y^tre�my#eIrt to the Worker% polo
Compensation Califomia. L Y 4s3 WA SYSTEMITREATING
�p�� to Receipt is
Q z Applicant J •—W�x--
z NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should NEW R AL FILMS. SQ.FT. TOTAL:
[/] become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall he deemed revoked. .DING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that them is a construction lending agency for the perfinmance of
U O the work for which this paten Is Isaued(Sec.3097,Civ.C.) / ELECTRIC FEE
Lender's Name
O F Lender's Address - QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
U I certify that I have read this application and state that Ne move information is
�" a comet.I agree to comply with all city and county ordinances and stow laws relating to PERMIT ISSUANCE MECHANICAL FEE
rpj building construction,and hereby nuNorizereprommatives ofthis city menteruPon the CONSTRUCTION TAX
U 7 above-mentioned propeny for inspection purposes. ALTER OR ADD TO SUCH.
G7 (We)agree to save,indemnify and keep hamdess the City of Cupertino against
liabilities,judgments,cons and expenses which may in any way accm tiloinstsaid City AIR HANDLING UNIT(TO 10."CFM)
in ,,.aca of the gaming of this permit.
' AIR HANDLING UNIT(OVER 10,000 CPM)
llusture of Applicant/Commcmr Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) - Date Receipt If
Will the applicable'
future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1041,000 BTU) TOTAL:
Crede,Section 25532(a)?
13 Yes El No VENTILATION FAN(SINGLE RESID)
BOILER. ISSIANCE DATE
Wilhhea Ilcanmrfmure buildin COMP OR 100,000 BTU) r ,S ,
pp gby he Bay An it Air Quality Management
w
bazmdous air comuminan[s es defined by the Bey Area Air Quality Manegemem District? BOILER-COMP(OVER 100,0110 BTU)
11 Yea ❑No NEW RESIDENTIAL MECH. $Q.FT.
I have read the hazardous materials requirements under Chapter 6.95 ofthein 19,9SCalifornia Health A,Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a tenant,et it is my responsibility Certificate
the (/f
occupant building
of the res not
which must ta mat prior m issuance of a Co matifte of
(kcupancy.
Ownerncy. rued an - Data TOTAL: ISSUED BY:
OFFICE