27754 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1 - I •L CTRL A PERMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG n C
J
BUILDING PROJECTIDENT'IFICATION LLC
BUILDING ADDRESS: 1
B/,ky.y ��`` SANITARY NO. APPLICA'DON SUBMITTAL DATE
bl �- "`� vY/� UNG`# LOT#
O IiRS NA PHONE: COIIp'RACfO_R'y►1y4 _ LIC NO: N/C CONTROL#
,WdLARCHI1MCTA7NGINEER: LIC NO, ADDRESS: •%W�•l■/..j ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLOC PWM MEC
PERMIT'ISSUANCE �/• LF
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑ca:z I hereby affirm that l am licensed underprovisionsofChapier9(commencingwith
F^100❑ Section 7")of Division 3 of the Business and Professions Cade.and my license is in PANELS
MY full fn.ind effect.
FZW License Class Lic.# UPTO201)AMPS
y?y Dam Contractor 201-1000 AMPS 5 FT.FLOOR AREA 5/SQ.FT.
ZOooz ARCHITECTS DECLARATION Q
OVER IM AMPS
O Z—❑ I understand my plans shall be cud ses public mcarea
Fin(=� SIGNS ELECTRICAL 1
QyNJ Licensed Professional
WyccQ OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOym v I hereby affirm that I aexempt from rhe Communes License Law for the
W 3 a y following mown.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires apconit to construct,alter,improve,demolish,or repair any strvetum
to its issuance,also re the applicant for such to rile a signed statement POWER DEVICES
prior quires PP permit g
p that he is licensed pursuant to the provisions of the Contrvcmr'e License Law(Cheprcr
a o�' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
–,.c, or be is exempt herefrom and the basis for the alleged exemption.Any violation of
Section]OJIS by any applicant for emit pessubjectstbe appl icam to a civil penahy of OWLETS-SR'D'CUES-FIXTURES
i to than live hundred dollars(1500).
❑ NEW RESIDENTIAL F.LEC . SQ.FT. STORIES TYPECONSTRUCDON
� husowncrnfthe property.ormyempinymswiN wogee as theirsolecompensadon,
n will wmk.Cosi swcmreisnotiamicense Law
apply I..Business
send Pmfcssimns CNe:The Conaactalx License Law Das not apply to an owner of
property who builds or improves thercan,and whodoes such work himselforthroughhis OCC.GROUP RES.UNITS
own employees,provided that such impmvemenm am not i ntendedor of fered for sale.If,
however,the building orimprobemeaa iswld withinone yearafcompletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lasawnerofthepmpertyzawlu' crae.z with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sa.]044, este and feaswas Cade:)The Comuant.
Uasmxel.awdoesnotap wnerofpropen whobcilds or improveitbemoa,and PERMIT ISSUANCE �
whom projcers withecomrecmrts)ieensed pursuemmthe Contractors
LiceALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
nse
❑ 1 am acmpt under Sec. ,B is P C for this reason BACK PLOW PROTECT.DEV ICE OUTSIDE FEES
SANITARY Y N
Owner_ Dum RECF.IPTp
AINS-FLOOR.ROOP.AREA.COND.
WORKMAN COMPENSATION CLARATION SCHOOL TAX V N
- ❑ ]hereby fftrmthatlhavea iifscamofeensen to self-insure,or a certif sof Fl ORES-PER TRAP RECEIPT#
Workers'Com mss alas 'B aopyth reof(Sec.7g00,L . which PARK FEE RF.CEIPI'#
coveriallearp] e G -EA.SYSTEM-IINC.4OUTLETS
Policy# BUILDING DIVISJOW0FE1 S_
Company GA -EA.SYSTEM-OVER41p) PLANCHECK FEE
❑ Cenifed upy sh by fornished.
❑ Certified ropy s Bl d with the city i ndivision. OR iASRANDUSML WASTE INTERCEPTOR GRADING ME
Cf:RTIIICATE OF ION FROMS�GR.KER GR SE TRAP SOILS FEE
ON INSURANC
(This himineed nm bac pleted ifthe permit is far allars SE ER-SANITARY-STORM EA.20(1 ENERGY FEEorlesa)Icmif Nminthe fo once of wok rmitis is ed,1eh 11 W PER HEATER WNPNT/ELECTR
not employ any Te in y mann o oma j to a Worker% PAID
Congenital Li of C#li min. Dnt W ER SYSTEM/TREATTNG Dat Receipt#
Q z Applicum
z 0 NOTICETO APPLICANT 11 after making is Ce i nmol Exemption astound NEW RESIDENTIAL PLMFL SQ.FT. TOTAL:
fn become wl co m the Work is Compel and provis m of the Labor e,you must
forthwith comply with such noisionsorahispermiubvllbedee revoked. BUILDING FE
W rr v SEISMICFEE
CONS UCTION LENDING AG Y
Uz Ihercby affirm ahenherc'xacmtstrmtion lrnJi grncy for the performance of L: ELECTRIC FEE
O the work fur which this permit 'sued(Sec.3 'v.C.)
Leaders Name
u-' F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I anify that I have mad this application end into that the above information isMECHANICAL
Mk
correct.l agree to comply with ml city and county ordinances and state laws rclatingb PERMIT ISSUANCE
�-" V) building construction,and hereby amhoriu representatives ofthis city to enter upon the ^ CONSTRUCDONT
L) 7 above-memioned property for inspection puryous. ALTER OR ADD TO MECH.
tom- (We)agree to save,indemnify and keep harmless the City of Cupertino against
liubiliaiea,judgments,co dexpcnxaa h! hmay' anyway true t(pgjpst AIR HANDLING UNIT(TO 10,000 CFM)
in nmseyue enf g ting of permit, lam/
AIR HANDLING UNIT(OVER 10,000 CFM)
Si nm •of Ap licem/Comma Dam EXHAUST HOOD(W/DUCT) PAID
HAZAROO Sh RIALS DISCLOSURE HEATING UNIT(T01130,BW BTU) Dem taiga#
Will aM1<opplicant or fm building occupant norc or handle herardous material HEATING UNIT(OVER I130,1p0 BTU)
m defined by the Cupertino unicipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532p)? VENTILATION FAN(SINGLE RESOD) Afts. Id
❑Yes ❑No
Will Ne vpplicanaorfmurebuildingoccupanmuequipmrnmrdeviceawhichemit
BOILER-COMP(JI{P OR 100,000 BTU) NCE
hazardous air comwninants as defined by the Bay Arm Air Quality Management BOILER-COMP(OVER 10,0130BTTJ) G,k
Dinner? cG "9
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ,FT.
1 have mad the hazardous metenals requirements under Chapter 695 of the �r�,rl� �k
Culifomio Health&Safety Cade,Sections 25505,25573 and 25534. 1 understand that 4
if the building door m not cuugly have a mount,that is any responsibility to notify the
ltue
occupant of the requirements which must be met prior to issuance of a Cenificate of
Occupancy.
Owner nr autbnmeJ gent Dem A ISSUED BY:
OFFICE