27175 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO �'DTh - 'LnLrRICAL PERMIT NO.
APPLICATION/PERMIT PING PROc-MeDENTICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27175
kkkiltDING ADDRESS: SANITARY NO. APPLICATIONSUBMDTALDA]E
e _ AY UNIT LOTH
OWNI2RS NAME: HONE: NIRACfOR'S NAME: LICNO: lob
N/C ONT
III'ECTAMOINMR: LIC NO: ADD ❑
QTY. - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
CONTACT: PHONE:
' '""1p""` BDG EkE< PLUMB MECH
PERMIT ISSUANCE /C�] El El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RFSIDENTW. JOB DESCRIPTION
Graz I hereby ufEnnuat l am licenxdunderpmvisiomsofaapter9(c9 encingwith
�00 Swim7000)af Division 3ofthe Business and Professions Cad,and my liceme is in
PANELS
1<.Zfull force and effect. clsisis,
License Class Lic.N UPT0200AMP5 `/w�V
y<co Data Canlnclm 201-1110 0 AMPS
FNS ARCHITECT-S DECLARATION SQ.FT.FLUOR AREA S/SQ.FT.
Z Os_n�O? I understood my plans shall be used as public records. OVER 1000 AMPS w�• .yyy
g=4 Licensed Professional SIGNS ELECTRICAL
pew< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. JD— ` `►T' V
aOyF 1 hereby off m[bar I am exempt from the Contractor's License Law for the
3 a ee following reason.(Section 7031.5,Business and profusions Cade:My city or county TEM.METER OR POLE MST.
I" which requires a permit to construct,elorr,improve,demolish,or repair any structure
anWY� r to its issuance,also the applicant far such Go file a signed diamond POWER DEVICES
prix requires pp perm gra
y)500 the he is ncingW pursuant to the provisions Df Ne Canvecness License law(shouter /yp
v. 9(commrncing with Section]000)of Division JofNe Business and Professions Code) SWIMMING POOL ELECTRIC ypL(1 N ^�
„ce orthatheisexemptthemfmmandthebasisfortheallegedexemption.Myviolationof O SW} -
FZa Sec' ]0JL5 by any applicant forapermit subjeesthe applicanno ecivil penalty of OUTLEfS-SWITCHES-FIXTURES
� C n rethan Bvehundreddollars(5500). NEW RBSIDPNTW.BLECIR _SQ.PI'. STORIES TYPECONSTRUCTION
utill I,mowncroftheproperY.ormyemployeewith wages satheirsole misers etim,
a 'lidothe work,and the structure isom intended orofPored for sule(Sce.]094,Business
NProfessions Cade:The Contractorla
's License w does not apply 0 an owner of
pm whobuilds orimproves thereon,andwhodoessuchwork himselfon0uoughhis DEC.GROUP RES.UNITS
ownemployees,pmvidW thatsuchimpmvemmomnot immndW oroffered fofeale.If,
however,the buildingor improvement is sold within one year ofccmplefim,the owner- TA
builder will have the burden of proving that he did not build or improve for purpose of
�/ ❑ I,mowneroFlhe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7144,Business and Professions Code)The Contractors PERMIT ISSUANCE
Licenselawdoesnotapply town ownerofpropeny whobuildsor impmvesihereon,and
whocammetsforsuch projects withacontmcmr(s)licensed purmamm the Conuactor'a pLTFR-DRAIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUT SIDE
SANITARY Y N
Owner Dale DRAINS- OORROOF A OND, n"1 RECMPTN
WORKMAN COMPENSATION DECLARATION �' ' ^A f—' t CHOOLTAX YN
❑ Thereby affirm thatlheveacenificde of conxnno self-insum,orecenificam of FIXTG -PE TRAP RF.CF.IPI'p
MalWorker'Crematoriumlmumacc or a emitted emythereed(Sec.3800,Lab C.)which ARK FEE Y N
emonsallempleyeehundeffiispernad. GAS-EA.SYS M-lMC.40UTI_E7FS RECEIPT#
PolicyN �� BUILDING DIVISION FEES
Company GAS-EA.jYSTHM OVER 4(EA) t ! PLAN {ECK FEE
❑ CenifrM copy is hereby famished.
❑ Cenifedropy iv fled wiN the city inspection division. GREAS USTRL _-GRAL&GFEE
CERTIFICATE OF MEMPTTON FROM WORKERS' GREASETRAP SOILS FPE
COMPENSATION INSURANCE
(Tltixsection need not becompleted lithe permit is formahundrW dollars($10(d SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued.)shall WATER HEATER WIVENT/ELECIR
was employ my person in any mender so as to become subject to the Worker' PAID
z Compmnws
ntialaof Califomie. Date WATER SYSTEMITREATING Date Receipt
Applicant
z 0 NOTICE TO APPLICANT:If.who making this Centiliter,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workars Compensation provisions of the Labor Code,you must
� > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
C>aQ CONSTRUCTION LENDING AGENCY SEISMICFEE ,
zI hereby affirm that Nem is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE a--
Lenda's Name
OI—' Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W1 cenify that I have read this appliced.and mate that the above informed.is - MECHANICAL PEE
coma I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
Cn buildingconstruaion,and hereby authorize representatives ofthiscity menterupon the CONSTRUCTIONTAX
L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hardest the Cistj of Cupertino against
liabilities,judgmems,cossandexpers which may innn w " st raid Ciry AIR HANDLING UNIT(TO 10,"CFM)
17
wnx9ucnce of Ne grating of this pemdic
AIR HANDLING UNIT(OVER 10,0011 CFM)
Signam ApplicanJCo nwo poor EXHAUST HOOD(WMUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt N
Will the applicant or future building occupant store or handle Imallous material HEATING UNIT(OVER 100,000 BTU) TO
as defined by the Cupunim Municipal Code,Clarion 9.12,similar Health and Safety
Cade,Section 25532(u)t VENTILATION FAN(SINGLE RESID)
❑Yes- 13No
ISSUANCE DA E
_seWitchieepplicanmrfuwre huildinguccupam uxequipmem0rdevicnwhich emit BOILER-COMP(3HP OR 100.000 BTU)
oto an,eonmminms es defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
imict G1
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.Ff.
I have new the hazardous materials requirements under Chapter 6.95 of the FI D
Califomiu Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility in notify the
occupmt of Ne bifuirem<nss which most be met prior to issuance old Certificate of ♦ 'P
Occupancy.
Owner tar euthorixed agent Data TOTAL: ISSUED BY: ry��_-
OFFICE