27198 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - -L.,MICAT. PERMIT No. q p
APPLICATION/PERMIT PLUMBING BUILDING DIVISION t_BUIIAl1Y;PR0JF.CI'IDNNTIFN'ICA 1 O
ICATIIIN
BUILDING ADDRESS: SANITARY NO. API'LIGTION SUBMITTAL DATE
2 a UNIT# LOT# 16 '2774T
OWNERS NAME;: PHONE: C NAME: LIC NO:
—,� NIC CONTROL#
RC1 INP.E : LIC NO: ADDRESS: ❑
CONTACT: PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUII
B MEC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LY LOB DESCRIPTION
M=Z I hereby affirm that I am licensed underprovisimsof Chapter9(crmmencing with
FJO{ CE rce addSmile.7000).f Division 3 ofthe Business and Professions Code,and my license is in PANELS
•- '
K U+I LI full fod effort. �}S
6Zy( [.loan.Class Lic.g UP TO 200AMPS 1 x
on d Date Cmntmcm, 201.1"AMPS
z8n3ARCHITECPS DECLARATION 0VER R)(IOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I understend my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
Cys OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Y
�q(OaU I hereby affirm thin I and exempt from the Conown.e.License Law farina
In 3 LL tifollowing reason.(Section 7031.5,Business and Profession Cade:Any city ar mumy TEMP.METER OR POLE INST.
IS�l which requires a permit toconstruct,alter,improve,demolish,or repair any structure
� Y2 print its issuance.also requires the applicant forsuch Permit to rile a signed statement POWER DEVICES
4411 atC that he is licemed pursuant w the provisions of the Contractors License Law(Chapter
Kp
0 9(commencing with Section 7M)of Division 3 of the Business and Pmfcedorm Code) SWIMMING POOL ELECTRIC VALUATIONa
,--no or Olathe is exempubemfrom and the basis for thealleged exemption.Any violation.( OUTLETS-SWITCHES-FIXNRES
Z GSection 7031.5 bm y any..plimfor a palmi,subjects the applicant to a civil penalty of
not mole than five hundred dollars(SSW).
❑ I,asownerofihepmperty,ormyemploymswithwagesastheirsolecompensation, NEW RESIDENTIAL ELECfR —SQ.FI'. STORIES TYPE CONSTRUCT ION
n3� will do Ne work,and Ntwoodwe is not intendedmoffered for scale(Sec.7044,Business
and Professions Code:The Contactors License Law does not apply to an owner of
property who buildscrimprovesthereom,andwhodmessuch work himselfordwoughhis OCC.GROUP RES.UNITS
own empleyees,providW Nat imehimprovementsamnot imendedoreffered torsade.If.
however.the building or improvement is sold within one year ofeemplt.ion,theowner-
builderwill have theburden.f thin he did not build m improve for t f TOTAL:
proving P P ryoseo
sale.). QTY, PLUMBING PERMIT FEL? Ia.000 ZONE APN
❑construct
the r Mimi
pmpeny,am Business
ss add onwaiio s Craiee The Comcmrx b
omwd the projmt fpm.7094,Business pa Professions Cod J The Contractor's
does notapply wan mwncmfpropenywensed dsmrimprovee Conam,end PERMIT ISSUANCE.
wh.cmm .,fonmch projects with aconrmemr(s)licensed pursuanttothe Convan.re
License Luw. L ThSt(dA> FEE SUMMARY
❑ 1 am accept under Sec. ,B&P C fm this rees.nOUTSIDE FEES
9A& FLO R F. SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECF.IPf#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm that l have a cenifcate.femasenuo self-insure,or a certificate of FI%TURPS-PF.R TRAP RF.CLIPfp
Wmkt.f Compensation Insurance oracmified copy theremffSec.3800.lab CJ which PARK FEE Y N
ersall employee'sundes this permit. GAS-EA. C.4 RECEIPT'#
Policy# BUILDING DIVISION FEES
Casuistry GA .SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished. Fal
❑ Certified copy is filed with the city inspection division. S 1 GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' AE&SETRAP
i,slon rho
COMPENSATION INSURANCE u
(This section need not be completed ifthe permit is Intone hundreddellwa(SIM) SEW
artless.)
I certify that in the performance ofthe work for which this permit is issued.I shall WAg��Aft1
rte employ my person in any mmt. as an m to become subject t.the Workers' Aing add • S3
Compensation Taws of Cnlifomin. Dem WA Data Receipt it
O z Applicant on
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RUMNAWW $ TOTAL:
.y. become subject to the Workers Compansstion provisions ofthe Labor Code.you must
a > forthwith comply with such Provisions m this permit shall be dewned revoked. llipwrIllso BUILDING EEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FHE
z I hereby affirm that there is a construction lending agency for the Performance of TOTAL: ELECTRIC FEE
O he work for which this permit is issued(Set.3097.Civ.CJ
lander.Name I
0 F Lenders Address QTY. MEC HA CAL PERMI FEE PLUMBING FEE
WI certify that I have mad this application and state that the above information is aa�
Pr
. mi.I agree to comply with all city add county ordinances and state laws relating to PERMIT0wre
V)
building cooathom
uction,and hereby authorize representatives alibis city mmr.p.n the
CONSTRUCTION TAX '
above-mentioned Property for inspection Purposes. ALTER OR ADD TO MECII.
(Wc)ugmmsave,indemnify and keep myhismalina.any
eay of Cupertino s again,
inconsinprudgmcnts,cola andexpensesa aeswhich my in any weyaccrveageinst said City AIR IIA
.nsequenc clardmingofthie permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
d
Si nmre.f APPIiwnUQmtran.r am EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hnzwdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety HFATING UNIT(OVER 1 W,000 BTU) TOTAL:
Qx1e,See ..Cl5532(a)? VF,NTIIATION FAN(SINGLE RES1D)
❑Y5 ❑Na
ISSUANCE DATE
Will theapplicantorfutu ,buildingmcupmt umcquipmeat ardevices whicheird BOILER-COMP(THP 0R 100.00s)BTU) P p 1 D
azwd.us air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,(gp BTU) l" #''
hatrin?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. OCT 25 �g 4
I have read the hamtdms materials requirements unit.Chapter 6.95 of the C�1y air
Califomia Health&Safety Code,Sections 25505,25533 mit 25534. 1 understand that U/,
if the building does not currently have a tenor,Net it is my responsibility to notify the ur�WINO
occupant of Ne requirements which must be met prior to issuance of t Cenifsme of
Occupancy.
Owner or authorized agent Dom TOTAL: ISSUED BY:
OFFICE
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