27776APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PROJECT IDEN-1'IFICATION
PERMIT NO.
27776BUILDING
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
///�s �LA�
Sc IT# LOT#
WNER NAME: PHONH:
CO R'S NA r w_ 1% LIC NO:
16%1\
WC
❑
CONTROL#
RCHITECI'/ENGINEER: LIC NO:
ADD 'S
cell
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG CT PL MECI
'/�1 R syr
PERMIT ISSUANCE
25 1—`� 1. V
El
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Sectio 1000) of Division 3 of the Business and Professions Cade, and my license Ts in
full farce
Licen
APPLIANCES -RESLDFNTIAL
PANELS
UPT0200AMPS
JOB DESCRIPTION
i Date
201-1010 AMPS
ARCHITELTS D ds
I understand my plans shall be used ns public records.OVER
1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
l SPECIAL CIRCUIT/MISC.
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law far the
TEMP. METER OR POLE INST.
following reason. (Section 1031.5. Busincas and Professions Code: Any city orcnunty
1 which rectums a pemtit to construct, cher, improve, demolish, or repair any structure
PH., to its hamme,rdso requires thele'licant for such permit o file. aigncd natmem
POWER DEVICES
j that he is licensed pursuant o the provisions of the Convector's License Law (Chapter
i 9(commameingwith Section 1000)af Division 3oftbe Business and Professions Cade)
or that he iseaempt therefrom andthe basis to, thealleged exemption. Any violation.(
Section l031.5 by any nppli...I for a pennth
it,ubjects e applicam to a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
j t more then five hundred dollar (;500).
CII,asownerofthepmo tly,ormyemploymswithwagcsaslheirsolecampensation.
NEW RESIDCNTIAL EL[CIR .
S Q FT.
STORIES
TYPECONSTRUCIION
wi l l da the work, and the simctum is not i mended or offemd for sale (Sw.1D44, B us mess
11
and Professions Code: The Communes License Law does not apply to an owner of
Property whobaddsorimproveathereon,and wbodces such workhimseRorthrough his
ownemployces,provided that such improvements eramnimendedoroffenedforsade, If,
OCC. GROUP
RFS. UNITS
however, the building orimpowament is sold withinane yeaof complaion. the owner-
builder will have the burden of pmving that he did not build or improve for purpose of
�-
QTY.. PLUMBING PERMIT FEE
sake).
❑ I, asownerofthe propeny.am cxclusivcly conuactingwithlicensW consactont0
FLOOD ZONE
APN
onswcs the project (Sec. 1044. Business and Protection CWe:) The Contractor's
License Law does not apply to an.wncr of property who builds m improves thereon, and
PERMIT ISSUANCE
whoom actsfarsuchpmjems withacmm ter(s)licemedpunuanu¢rhe Contractor's
Liana, Law.
ALTER - DRAIN & VENT - WATER (RA)
FEE SUMMARY
❑ I em exempt under Sec. , B & P C for this reamn
BACK FLOW PROTECT, DEVICE
Oul SIDE FRES
SANITARY Y N
Owner Dare
DRAINS- FLOOR,ROOF,AREA,COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ IhereM1y affirm thmlhave acenifmam of consem to self insure. orattnifieemof
Workcrs'Compensntionlnsumnceon certified copy thereof (Sec. 3800, Lab C.) which
coven all employee's under this permit.
Policy #
SCHOOLTAX YN
RECEIPT*
FIXTURES -PER TRAP
PARK FEE Y_N
RECEIPT #
GAS - EA. SYSTEMA INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS-EA.SYSTf:M-OVER4(F.A)
PLANC .CK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GRHASFANDUSTRLWASIEI E OR
GRADIN EE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILSE
SEWER -SA ARY-STORM EA.
ENE GY FEE
(This section twolmt 1wemopla.E tithe permit is forms. hundrsddollars($IN)
orless)
WATER TER W/VENTfRLE
AID
Dote Receipt
I certify thetmth r arca ofthe k hick thio pe it isirsued,l shall
not employ any any ty#nn war s aMF0. skari
Compensetio sof Califs _
APPlica Q —
WATE SYSTEM?R Tl
NOTIC OAPPLICAW.1f..Orm ssg'u,CmrEcateaf Exemptmn,youshould
become subject to the Workels Compensation Provisions of the Labor Code, you must
NEW RE DENTIALP
TOTAL:
forthwith comply with such Provisions m this permit shall be deemed revoked.
BUILDING G FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hemby affirm Net there is a conswy leMing agency far the perfacommer of
ELECTRIC FEE
the wad for which this permit is issued�6e9�097. Civ. CJ
Lumber's Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING
I certify that I have read s application and state that the shove Information is
correct. l agree to comply with all city and county ordinances and stats laws relating to
buildingeonstruaion, and hereby euthodmrepresrntatives ofthis city menterupon the
abm
ove-ention ny for inspection purposes.
PERMIT ISSUANCE
MF.CHAN
ALTERORADDTOMECII.
CONS NTA
(We) , indemni( kap hamdess Ne City of Cupertino egvnat
earms,cosB
liabilib and hich maymany way ecerueegeinst said City
n
AIR HANDLING UNIT (TO 10,000 CFM)
ina yuan ofth oh pe
,2
U
AIR HANDLING UNIT (OVER 50.000CFM)
gnmure of APPlicunV rte
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT GO I00,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt
Will the applicant or fumm building occupant store or handle harnrdom materiel
as defined by IM Cupenio Municipal CWq Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
VENTUAT10N FAN (SINGLE RESID)
Cole. Sati El YSa32(a)1 0 N
Willtheapplicantorfuwm buildingacupantuse equipmemmdeviceswhich noir
BOILER - COMP (3HPOR 100.000 BTU)
ISSUA C DATE
sw.ardous ; air cuntamimnts a defined by the Boy Area Air Quality Management
i.triel
BOILER 1(0,000 BTU)
❑ EI Yes No
4
�qR
NEW RESIDENTIAL FT
MECH. SQ. .
I have read the boamok us materials ".i ... is under Chapter 6.95 of the
California Health & Safety Cede, Sections 25505,25533 and 25534. 1 understand Nat
C��f-`
not rre
the building does cuntly have a tenant, that it is my responsibility to notify the
occupant of the na,mements which must be at prior to issueatt of a Certificate of
Occupancy.
�. Ig
(,.91
G~Cn
ISSUED BY:
Owne mitchedaed agent Datc
T
OFFICE