27124 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B IMINU-hLhU I RI A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 27124
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. //'j SANITARY NO. AP�CA I NSUB�ALDATE
/
/ O,Z 1 0-oL?3 C- UNIT LOTp
0 N SOAMA[&- PHONE: cow R' ME ICNO:
`( 472 N/C CONTROL p
•ARCI CTRiNGINEER: LIC NO: AD,gybo `
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I ❑
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
- PERMIT ISSUANCE .ZVO ❑ fC/ ❑ I�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ISO DESCRIPTION �-•r-
mwz Ihereby of nnothat l am licensed underprovisionsof Chaptar9(commencing with
P 00E Section IM)of Division 3 of the Business and Professions Code,and my license is in PANELS
��U full force unJ effe �_ /� e,(� `Ct
FiW License Bless /L� Lic.p�' UPT0200 AMPS (.Ls7jy-Yy4� -vy ✓ �-L� (-, IGLYy
mQ0. Dae ( Corin 20L I(IW AMPS
F,IZ ARCHITECTS DECLA ATION SQ.IT.FLOOR AREA E/SQ.FT.
00Z(:O I understand my plans shell be used m public rccards. OVER 1000 AMPS
re,vi h sea SIGNS ELECTRICAL.
�Y•F„_1 Licensed Professional f�0.❑'u OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
00.1„ I hereby alfrm that I am exempt from Inc Cmura ms's License Law for Ne
{3{�p a following mvsan.Need.7031.3,Business aM Professions Cade:Any city or county TEMP.METER OR POLE DIST.
I--. v5WM1ICII r[gUlms a ptmlll to fonSWCt.aDtr.ImplOVe.demol6h.Of Taped!tlny aPYC1aR
}� faits issuance,also upas the applicant forsuch Permit a signedstatement POWER DEVICES
K poor req app pract
yl K Z p
that he is licensed pursuant m the provision ebbe Contractors License Law(Chapter
9(commencing with Section 7010)of Division 3 of fie Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W�a or that he iseaempuherefrom and the hads for the alleged exemption.Any violation of OUTLETS-SWITCHIS-FIXTURES
�z2 Section 7031.3 by any appitcnnt fora permitsubjerts theppplicant ma civil penalty of
EC G not mom Nan five hundred dollars(5500). .FT.
W � ❑ I,mownerofthepmNm,amyemployaswithwagesutheirsolecompnsatiI. NEW RESIDLNTIAL ELLCI'R SQ STORIES TYPE CONSTRUCTION
it,3 will do the work.and the structumis not imendwlofoffered for sale(See.7094.limmoae
and Professions Cade:The Contracmrs License Law does not apply to an owner of
property whobuildsorimpmvestherwn,and whodas such work himselforthroughhie OCC.GROUP RFS.UNITS
own employers,prov ided that such improvemts a
enre nm int ended or offered for sale.If,
however,she buildingorimprovemem is and within oneyearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowneroftbepmpay.mnexclusivelycuntratingwithlicensedcosnmemrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:7 The Contractor's
License Lawdoesnot applytoan owneroffamprty who builds orimprovesthereon,and PERMIT ISSUANCE
whocommeuforsuch projects with acontrachums)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER BEA) FEE SUMMARY
❑ I am exempt under Sa. B @ P C for Nie rtusnn
BACK FLOW PROTECT.DEVICE DE
SANITARY Y N
Owner Data RECEIPT
p
DRAINS-PLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby elfrm lhalhnveec<nificatc of censers to self-insure,ma ttnifcvte of RECEIPU#
Workers'Compensation FIXTORES-PER TRAP
pensatianlnsumnce or copy thereof(See. LebCJ which PARK FEE YN
covers ell em y t ' GAS-EA.SYSTEM-1 INC.40l1TLF.TS
RECEIPTp
Policy p BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER 4(EA) PL ECK FEE
❑/Cmifed copy is hereby famished. if
Qk�Canned copy is filed with the city inspection division. GREMNINDUSTRL WASTE INTERCEPTOR G GFEE
CFRTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP OILS FEE /
COMPENSATION INSURANCE
(This section maxima be completed ifthe permit is foronehundrwidollars(E100) SEWER-SANITARY-STORM EA.700FT. E YPEE
ar less.)
I cerifytha lame performance of the work for which this permit is issued.I shall WATER HEATER WINENT/RLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of Cilifamia. Dam WATER SYSTEM/TREATING Did. Receipa
Q Z Applicant
z7P NOTICE TO APPLICANT:If.after making this Certifscaeof Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F� became subject to the Worker's Compensation provisions ofthe labor Code.you must
llla^^^ ' forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
D-I Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
-P�j- Z I hereby affirm that them is a construction lending agency for N<perfsaince of ELECTRIC PEE
Q the work for which this permit is issued(See.3097.Civ.C.) TOTAL:
Lenders Name
0 U. F Lenders Address QTlY. MECHANICAL PERMIT FEE PLUMBING FEE
LVlI1 certify that 1 have read this application and swam that the above information is MECHANICAL.ME Q�/
ecoat.l agree to comply with all city and county endurances and sum laws relating to PERMIT ISSUANCE •lid .�6'
tbuilding exastructiomvnd herebyauthodu rtpmxntmivesof this chyw vnterupon Ne CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liubilities,judgmenu,costs and<xpenus which mnyin my way eccmeageinat said City AIR HANDLING UNIT(T010,000 CFM) 1 .00
in WWW eyucnce of the gmnting of Nis emtit.
AIRHANDLING UNIT(OVER I0,000 CFM)
Siemaureof ApplPPlicart/C/ontractor gD(y/`I EXHAUST HOOD(WIDUCp PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101,000 BTU) Data Rai ipp .�.�nkt
Will the applicant or fumm building occupant sum or handle h taxa doses material I i9VGp'W
as defined by the Cupertino Municipal CodHEATING UNIT(OVER 100,1100 BTU)
Code,Chapter 9.12,and the Health and Safety TOTAL:
Code,Section 25532(x)? p{ VENTILATION FAN(SINGLE RESID)
EI Yes l(+No ISSUANCE DATE
BOILER-COMP(3HP OR IN."BTU)
Will theapplicanlnrNmrc buildingacupantnuequipment ordevi<es whichetdt
hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-
COMP(OVL'R IW,WO BTU)
❑Yea 'pin NEW RESIDENTIAL MECH.-SQ.FT. OCT �� 19941 have read the hazardous mmerivls requimmenu under Chapel 6.95 of the
Califomia Hwlth&Safety Cade,Sections 25505,25533 and 25534.I understand that
I f the building das not cane l have cement,Nat It is my responsibility to notify the CII I NI vVfGlll ll%%J
cups of the reyuirewanu 'ch nst be ma prior m issuance o a Ce eme of
Occup
D /
Owner or anthorized ager Dae TOTAL: d0 ISSUED BY: tea• sV- T
OFFICE