27732 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO IL 1 -F..S. RI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. (� /�
BUILDING.PROJECT'IDENTIFICATION G JG
BUILDING ADDRESS: 1m, SANITARY NO. API'LLIICfffATIONSUBMMI E'
TALDAT
10131 �V % PI� UNIT# LOT# / JN�lA
OWNERS NAME: PHONE: CONTRACTOR'S NAME LIC NO:n r N/C CONTROL#
18Vt�1 P•3G6• ao
CHI' C GME' CNO: 0 ADDRESS: ❑
ONTACT: PHONE:
/1/I� 7 QTY. ELECPRIC PERMIT PEE BUILDING PERMIT[NFO
yyyy������,�
�DOCZ"tet. #h r - 7&•�/ PERMIT ISSUANCE BLDO ' ECT PLU_ MB EO
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL [OB DESCRIPTION
ozz Ihereby affirm that l sm licensed under provisions of Chapter 9(com
mencing with
1400 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
fall� , LietaeClace ffect. UPTO200AMPS
` Fyy Deems Clue ate Contractor 201-ILIO AMPS
Z O 2 ARMIITECPS DECLARATION SQ.FT.FLOOR AREA 4/SQ.P .
OVER IfKKlAMPS
BYO I llpdersjandmyplansAA seJy. _ospuhlierecords.
W r(•�Poffl'iflA L'/ ANN�I/l , SIGNS ELECTRICAL
4 LtcenaW v un IT
6yg
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O a F 1 hereby ..(So that 1 am exempt from Ne Co cion, o License Law for the
3 tr-ma
which
Permit
to construct,
and Profusions Coda:Any city or county TEMP.METER OR POLE INST.
which requires n permit re conrwch altep improve,demolish,fi repair any structure
�.y}$, to its issuance,also re the licant forsuch Ino fileasigned ammmrnt POWER DEVICES
prior quires PP peon
aoyy <p 9(Comsnlicensed punction the provlsionsof the Contractors License Law(Chapter
' 9(commencing with Section](M10)of Division3ofNe Business and Professions Code) SWIMMING POOL ELECTRIC
VALUATION
IZ,n othat oheirexempt byan applimandtbebasisforthectsthedexcmption.Anyviolatiunof OUTLETS-SWITCHES-FIXTURES 2Q D��
yet Section 7031.5 v anyapplicantfor apermit subjects the applicant macivil penalty of ((fJ cd
p t mare than Ove hundred dollen($SW).
n❑ Lxsownerofthepropeny,ormyemployceswitb wagouNeiraoleaompensetion, NEW RFSIDPNTIALELECfR _SQ.PT. STORIES TYPE CONSTRUCTION
3� will do the work.snd the structureis not inumdedor offered forsale(Sec.]IW4,Business
and Professions Cade:The Conoacme,License Law doer not apply man novae,of
property whobuildxor improves thereon,and whodousuchwork hlmulforthroughhis OCC.GROUP RES.UNITS
ownemployees,provided Had such improvements are notintendedoroff seal forage.If,
however,the buildingor improvement is sold within oneyear ofcompletion,the owner- TY
builder will have the harden of proving that he did not build or improve for purpose of
sale.).
❑ I,as nwncnrfthe propeny,amex<lusivelymno-aning wiNlittnsed cono-ucton to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Conswet the project(Sec.7044,Business and Professions Code:)The Conuacme. PERMIT ISSUANCE s'License Law does not apply to an owner of property who bel ldr or i m proves t hereon,and
whocontructs for such Projects wit acomanctods)Iicenudpunuam toric Contrncmis ALTER (EA)License law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE, SANITARY OUTS I OR FE ES
Y N
Owrmr Dote RECEIPT#
BOOP,AREA,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, COND, SCHOOL TAX Y N
❑ ershereby Corxffirm thatInsurance
Or acamof Cnnaenitastf(SerWe.orottnif whi of RECEIPT'#
ohers'Compenmtiun lrmumnce oracertifiW copy thereof(Sw.3CJwhich PIXTUBBS-PERTRAP PARK FEE Y N
coven all employee's under this perand. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE e
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection divixi GREASFIINDUMLWASTEINIERCEPTOR GRADING FEE
CERTIFICATE.OF EXEMPTION MWORKERS' GREASETRAP SOILS Hr.
COMPENSATION INS ANCE
(This sec'um edom be completed ifthe it is fmmrc hundred rich.(SI00) SEWER-SANITARY-STORM EA.2001"1'. ENERGY FEE
or lest.)
I ttnify that in th<peKormunre ofthe ork forwhier Nis pemtit is iuued,ishall WATER HEATER W/VF.NI'/ELECIR
not employ any person in any rearm as m became subject m the Workers PAID
Compensation laws of Califomia. D c so ATFR SYSTEM/1'RLATING Date Receipt
O z Applicata
z NOTICE TOAPPLICANT: ftumakingthhicettif¢amof xemption.youshould NE RESIDENTIALPLMB. SQ.FL TOTAL:
V)j became subjecuo Ne ars Compensmion pookib soflh or Ccde,youmust
forthwith comp) such provisions or Nis permit sh 1 revoked. BUILDING FEE
Gla Q CONSTRUCTION LENDI SEISMIC FEL' #_
z 1 achy affirm thar there isacnnswctio i gency for pemm�eo ELECTRIC FEE
U 0 the war forwhichmis permit is iss (S Civ.C.)
I andel N
rr Lmdcr' Addrerr QTY MECHANICAL PERMIT PEE PLUMBING FEE `
7" 0.L) 1 ably that I have read this t on ad smut above information is MECHANICAL.FEE
mrrtct. agreemcomplywiNall city and Duct oNinan sand ntam lawsmiltingm ERMIT ISSUANCE
building nstrvaion,and hereby authodss ntadverof thiscity reenter upon the. CGNSTRUCHON TAX
U z above-men' ned property for inspection purposes. ALTER OR ADD TO MECH.
(We)a e to save,indemnify and keep hamnesa the Cityof Cupertino age' t
liabllitics,judgt ts,costs sndexpenses whichmay many way accrue,einst sai fry AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of nuumgof Nispermit.
MR HANDLING UNIT(OVER 10,000 CFM)
Signamreof ApplicarrUConv Data EUTAUSTHOOD(W/DUCD PAID
HAZARDOUSTFR
0 Yea C1 No
IALS DISCLOSE HEATING UNIT(TO 101J."BTU) Data Receipt#
WdItheupplicantorfeturebufldi occupantstoreorha a hazardous material HEATING UNIT(OVER BID,"BTU) T
as defined by the Cupertino Municipal C Chapter 9.12 d the health and Safety
Cade,Suti25532(x)? VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 1 W,00B BTU) ISSUANCEDATE
Willtireto aemmanmrfmure defining by0.Bay equipment ardevie Manageetnt r p B
Danieous nit rnnmminanm u defined by Ne Bay Arens Air Quality Management BOILER-COMP(OVER 100,000 BTU) /9 D
District?
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.FT.
1 have rtad the hazardous maedrds requirement,under Chapter 6.95 of Nc e{/ 19
Califomia f lealth&Safety Code,Sections 25505,25533 and 25534. 1 understand that l
if the building does not currently have a tenant,that it is my responsibility to notify the �/I UI• �•Ur
occupant of the ro,uiramenm which must he met prior to issuance of a Ccoi'fi ate of
tXc cY �/JW9T �IJK' To
Own roram arized gen Data TOTAL: ISSUED BY:
OFFICE