27788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-E R AL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL OO
BUILDING PROJV,CT IDF-NTIFICATION v o
BUILDING ADDRESS: SANITARY NO, APPLICATIONSSUBMITTALDATi
I u Q UNIT LOT# gam q kq
OWNERS N9/1F � Mli:PHONE: CO RACTOR'S LIC NO: N/C CONTROL#
I� AR '/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MICA
PERMIT ISSUANCE )C 'If ❑ El
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL ,eLx YJOB pIO, 10Matz Ihereby affirm licensed (commmcingwith
ISF'W
�00 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
C full force and eff f�
Fsit Is License Class Lic.p 9 S — UP TO 200 AMPS /LIT
m 6 y Dam Camra ear 201-1000 AMUS {ig�
Zoto z' ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ••D I und<rsund my plans shall be used us puhlic recoNs.
r-42W SIGNS ELECTRICAL
Q ...4I Licensed Professional
C�wU OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
�J34F,- 1 hereby affirm that 1 mar exempt from the Contractor's License Low for the
ppb following comer.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F.E: which requires a permit to construct,Wier,improve,demolish,or mpdr any structure
rgyt�� N priormitsimuuntt.else requires the applicant for such permit W file a signed statement POWER DEVICES
y C O that he is licensed pursuant to the provisions of the Cnmrucmr's Licenu LewCTn
( pur
R-C'.' ' 9(rommencing with Section 7")of Division 3 ofthe Businessend Professions Cede) SWIMMING POOL ELECTRIC VALUATION
F�._,, anhat he is exempt therefrom mdthe basis for the alleged exemption.Any violation of faiss—
z6 Section 7031.5 by any eppI Cant for a Permit subjects the applicanuoecivil penalty of OUTLETS-SWITCHES-MIXTURES
O nm mi,asown0vfthepreny,ofmyem). NEW RESIDENTIAL ELECIR _SQ.Fri. STORIES TYPECONSTRUCTION
❑ Lasowne,smodIpropcny.ormyemployeeswiNwed for thei(sole comp Business
L will doutework,and the he cture Commuternon ntendederoawcosfontapplyWe Ia a4,Business
ono Professions Code:The Contr«rors License Law does not apply mf,an owner of
is
propmywyees,pdoorimprovesth improvements
a ha ticch work erforofendrmelf,ur through his OCC.GROUP RES.UNITS
woe,,,theea,p building
orihatsuchoverse is
emsareneyearr compffemd forsaln1L
however,the building crimp of proving
is sold a did noneyeu or improve for ducpurpose of -w—
We.).
builder will have the burden of proving thn he did not build or improve for purpose of
❑ I,asowncrofthe property.ammclusivelycontracting with licensed conwcto.to QTY, PLUMBING PERMIT FEF. ------MOOD ZONE. APN
co mmot the projem(Sm.7094,Business and Professions Code:)The Contractors PERMIT ISSUANCE.
Licenu La w docs not apply m m owner of propmy who bui Ids or i m pmvm thetean,and
whocontraters forsuch Projects with a eontraetot(s)licensed pursuanttothe Commetoes
License Law. pLIER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this revan BACK FLOW PROTECT'.DEVICE OUTSIDEF,
SANITARY Y N_
Owner Data RECEIPT#
• m WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.RDOP.AREA,COND. SCHOOL TAX YN
❑ Ihereby affirm that l have a cenificate ofconsent to self-insure.or aanificaR of ' ECEIIT#
MIXTURES-PER TRAP
Wodcts'Compemetion lnsuranceora ttrtified copy,thcreof(S«.3gW,Lab CJ which ARK FEE N
rsallempleysixtroderdmispennit. GAS-PA.SVSTP.M-1 WC.40U TS E IPTN
Policy# B DIV ON PEES
Company GAS-P.A.SYSTI?M-OVER4 ) CHECK FEP
❑ Certified copy is hereby furnished.
❑ CenifiW copy is fled with the city inspection division. GREASFONDUSTRLINTEINTiRCEPfOR DING
CEWNFTCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is recant,hundred dollan(SIW) SEWER-SANI RY-STORMHA.2WFT, EN; FEE
or less.)
I certify that in the performance oflhe work for which this permit is issue,I shall WATER RW(VEN17ELECTR
nm employ any person in wY try m to the Workers' PAID
z Compensatip�a�T�ild' �Dn r s ��w�+ WATE YSTENVTREATING Da Receiptp
Applicant — r/�Uom�i(.I
� 0 NOTICE TO APPLICANT;If.after making this Certificates of Exemption,you should NE RESIDENTIAL PLMB. SQ.FT. TOTA
h. y become subject to the Workers Compensation Provisions ofthe Labor Cee,you must
Permit� , forthwith comply with such provisions or this Word h deemed revoked. BUILD GFEF. .a-
0. ❑ CONSTRUCTION LENDING AGENCY VdMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,O,C.) TOTAL: ELECTRIC FE
f.enEe/s Name
p U Lmders Address QTY. , MECHANICALPERMIT FEE PLUMBI
U I certify the I have read this implication and sane that the above information is
correct.l agree m comply with all city and county ordinances and!sure laws relating to PERMIT ISSUANCE MECHA 1 FEE
r 151th
building construction,and hereby comment,representatives ofmiscity tome,upon e CONSTRUCTION TAX
U �Z above-mentionW property for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and k9erliffrasirs the City of Cupertino against
liobilitics.judgments,costwndex ich may in y way memo against mid City AIR HANDLING UNIT(TO 10,0X10 CFM)
the 8tantimg is eswt
AIR HANDLING UNIT(OVER 10, FM)
Signumre of Applicam/Contmnor Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW, BTU) Date Ramiro#
Will the applicant or future buildingcocupent store or handle humorous material HEATING UNIT(OV IW,000 BTU)
as derided by the Cupertino Municipal Cale.Chapter 9.12,and the Haahh and Safety
Cale,Sccd 25532(e)?
D Ycs ❑No
VENTILATION 94(SINGLE RESID) -9 Irk
sAY ATE
Will the upplicumorfuwrebuilding«cupantuseequipmemmdevittswhichemlo BOILER-CO (3HP OR 1013,000 BTU) Y
huvardous air contaminants as defined by the Bay Arca Air Quality Management BOILER MP IW,000 BTU) -� J
•
District? ❑ ❑ - O
mnxyy Q
Yes
No NEW 'SIDLNTIAL MECH. SQ.Fri.
I have read the hazardous mrambils requirements under Chapter 6.95 of the ,"•, .lC ��C 4P
California Health h Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building docs net currently have a Rnanl,that it is my resp ureibilily to notify the
occupant of the requbemetds which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorisd agent Dale TOTAL: ISSUED BY:
OFFICE