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27958 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECI RICAL _ PERMIT NO. APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27958 BUILDING ADDRESS' IC SANITARY NO, APPLICATION SUBMITTAL DATE J •40 G. // UNIT# LOT# 3 OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: ••• NIC CONTROL# ARC � CONTACT: T:sjr; EER: G LIC NO: ADDRESS7102 VIfOAG CONTACT: t�G tl � PHONE �y QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO V /` ✓ 7 BLDG ELECT PLUMB MECH PERMIT ISSUANCE El F-1 0 LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION POO Iherebyaffrnthatl 3 arm,udun,,and rofesion,Coder ancommencing with POO full f c and of Division 3 arm,Business and Professions Code,and my licenu is in PANELS FC full force and elf t. Qu License Class (tJ�s3 UPT02MAMPS _ (��AZO—Conn.., v /6 Duce ARCHITECTS DECD AA. 3111-1000 AMPS ZOin Z..] ARCHITECTS DECLARATION OVER 11100 AMPS SQ.FT.FLOOR AREA $/SQ.FT. O y�O I understand my plans shall be used as public records. F rn t� SIGNS ELECTRICAL 6,y `i Licensed Professional E5, OWNER-BUILDER DECLARATION SPECIAL CIRCULOMISC. ip O W F 1 hereby of or that I am exempt from the Contractor's License Law for the W 3�to following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST, I�OOa.] which requires a permit to construct,alter,improve,demolish,or repair any structure Nab poor to its h1mance,also requires Neapplicant nutshell permit m flea signed statement POWER DEVICES A O that he is licensed pursuant m the provisions of rhe Contractor's License Law(Chapter 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION Qy 2 ormat he is exempt therefrom and the basis for the alleged exemption,Any violation of OUTLETS-SWITCHES-FfXTURE$ �Q Section 7031.5 byanyapplicant forapermit subjects the applicantr a civil penalty of / OO��J� not more than five hundred dollars($500} (B/ �Y � w ❑ Lasownernfthe NEW RESIDENTIAL F.LECTR _S . properly,ofmyemployed or offend forsalei(sole cumpensimear STORIES TYPE CONSTRUCTION will dothe wons Co the he Conttructure isnora License ofw doss no,apply to an Business and Professions Code The Cnmrucr.r's License Lew does not apply to an owner of - prapeny who builds or i mproves thereon,and who does such work himself.,through his wnemployees,providedthatsuchimprovements are n.titnendedoroffnd forsale.If, DGG.GRQHP RES.UNITS however,the building.(Improvement is sold within one yearofcompletion,the owner- TA builder will have the burden of proving that he did not build or improve far purpose of sale.). ❑ nQTY, PLUMBING PERMIT FLOOD ZONE APN I,as rofthepropenm y,aenclusively contracting with licensed nsed contractors nnsnuct the mamt(Sec.7044,Business and Professions Code:)The Contractor's License Lawdoes not apply loan.wnerofpraperry who builds or improves therromand PERMIT ISSUANCE whocomrams forsuch projects with aconoanorts)licensed pursuant tothe Connector's License law. ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY ❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE SANITARY YN Owner Dace DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT It WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N ❑ I hereby affirm that l have a certificate ofconsenfto self-insure,ora certificate of FIXTURES-PER TRAP RECEIPT# Workers'Compensation Insurance ora certified copy thcreof(Sce.3800,LaIn C.)which PARK FEE Y N covers all emploYeS's�uRder sp ytt GAS-EA.SYSTEM-I INC.40UTLETS RECLIPT# Policy # /yd� et,t'�O�j'�o0 BUILDING DIVISIOECLIFF FEES Compuny ��fQ�/[ GAS-EA.SYSTEM-OVER PLANCHECK FEE ❑ Certhim copy is hereby famish ❑ Cenilied copy is fled with the city inspection division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - SOILS ME COMPENSATION INSURANCE (This sermon need not be completedLthe pennit is fhronehundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or loss.) I really that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIR not employ any person in any manner so as m become subject to the Workers' PAID Compensation Laws of California. Date WATER SYSTEM/I'REATING pate eipr# O Z Applicata NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL: became subject o the Worker's Compensation provisions Offer Labor Code,you must [�� 1 forthwith comply with such provisions ar this pennildrill be deemedow.ked. BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE ✓R z I hereby affirm that hem is a consvumion lending agency for the performance of C) O the work for which this permit Is issued(Sea 3097.Civ,CJ TOTAL: ELECTRIC FE Lenders Name PLUMB E 0 E Lenders Address QTY. MECHANICAL PERMIT FEE W1 certify that I have read this application and stare that the elmve information to MECHA CAL FEE r�" correct.Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE 4�R�� V) buildingeonstruction,and hereby aurhorim micesentativeso(this city theater upon the V ✓ CON UCTION TAX V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII. (We)agree to save,indemnify and keep huntress the City of Cupertino against liabilities,judgments,costs andexpenses which may,in anyway secrueagainst said City AIR HANDLING UNIT(TO 10,000 CFM) in consequence or the granting of this permit. AIR HANDLING UNIT(OVER 10.0oO CFl1H Signature of Applicant/Commacmr Date EXHAUST HOOD(W/DUCn PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(Tb IOO,WO BTU) O am Receipt#, Will the the Cupnt or ertino a icipal Cod..C am score 2,and dle the He rdhus dSafrmaterial - as defined by the Cupertino Municipal Cede.Chapter 9.12,amd the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL: Code,Smtl 25532(x)? 0Yes E!rNn VENTILATION FAN(SINGLE RFSID) BOILER-COMP(311P OR 100,000BTD) ISSUANCE DATE Will the applicant orfuture building.ecupant usethuipment.rdevices whichemit hazardous air comeminant�y s,as defined by the Be,Area Air Quality Management ISSUANCE 100,000BTU) District? CI Yea uno NEW RESIDENTIAL MECH. SQ.FT. �� I have read the Safety Code, materials requirements ander Chapter 695 of the C/ fYIY Calirnmin Ilcahh&Safety Code,Sections 505.25533 d 25534. 1 understand that C if the building da s not currently have a Itarm,that it i y responsibility to notify theyr `Lroccupantofrhe em which mue met pri t morpre of a Certificate of // U Occupancy 'rein woerorant h agen Date TOkI6 1,1 r ISSUED BY: OFFICE