27083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO131NG-HLEC'I HICA PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL n OOQ
BUILDING PROJECT IDENTIF'ICAT'ION L
BUILDING AppR�$� UNIT. LOT SANITARY NO. APPLICATIONSUBMGTALDATE
- ' 'OW AMC: •�1Vj^/'�Y PHONE: CONTRACTOR'S NAME: LIC NO: O
SIC CONTROL#
R N EERLIC NO: B 3 ADDRCSS
1; 740
coNTACf:
PRONE:
C�L yr U(/a�fl//(�0d0/7F1'LSL
61L 2S ) p' G DD QTY _' LIEEGTRIC PERMIT /
BU
FEE
BLDG ELECT
PERPLUMB
L EM O O.M(77 G SSUANCE
LICENSED CONTRACTOR'S DECLARATION TANRIDENTW, INFO
ECH
I heub affrmthn l am licensedunder p ( gwith LOB DESCRIPTION
GKZ Y and
FoionsaimmC ter9 comylice s
�00 Section],(1(1)of Division 3 of the Business aW Professioru Code,and my license is in PANELS {�'a`/1�
� full fort and effect. llP T0200AMP5
GZ License Clens Lic.p
h=y Dom Coal. MI-1000 AMPS
, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.PT.
ZQ yZ
CZ-0
1 understand my plans shall be used as public records.
ns SIGNS ELECTRICAL
., MLicensed Professional
ged6 OWNER-BUILDER DECLARATION SPECIALCIRCUTUMISC.
0.x0.x O y U 1 hereby affirm that I an exempt from the Contractors License Law for the
W 3 a m following reason.(Section 7031.5,Business arta Pmfessiaru Code:Any city or county TEMP.WEER OR POLE[NST.
which requires n permit an concoct,alter,improve,demolish,or motor any structure
f Y prior to its issuance,also requires theapplicant fm such permitto fide.signednstemem POWER DEVICES
pj Q O then m is licensed with
Section the provisions of the Conbavm's Littnu law(Chapter SWIMMING POOL ELECTRIC
a%o�, 9(cmnmcncing with Sedion]OW)of Division 7ofthe Business and Profession Code) /� VALUATION
or thus he is exempt therefrom.ndthe basis for thealleged exemption.Anyviolatio'of / ^ — _ �'�
G Secti.n703l,5by.y.niicantf.,a,.itsubjenatheap,lic.,t..civil penalryaf OUTLETS-SWITCHES-FIXTURES /'s' I`07oI
nm more than five hundred dollars($500). NEW RESIDENTIAL ELCCfIE S .PI'. -W
C m ❑ I,asownerofthepmpany,ormyemployeeswiihwagesmtheirsolemmpeosation, Q STORIES TYPECONSTRUCfION
9!g_ widdo the work,and theswctum is not intended mattered forsule(Sm.]Is00.Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whobuildsor improves thereon,andwhodansuchwork hiwelforthrough his
cmployrea,pmvidedthat such improvememeerenotimendedmoffertd fmaele.If. OCC.GROUP RAS.UNITS
haw m.the building or improvement is sold within art ofemopletioo,theowner-
builder will have the burden of proving thv he did not build err improve for puryou of
s❑)l,wo nerofthepmpeny,omexclusivelycontmdngwilhlicens wn=tomw QTfY. ' i s,PLUMBING PERMIT FEE FLOODWNE APN
construct the pmjmt(Sm.71110,Business and Professions Cad,)The Cwtncmra pERMITISSUANCE
License Lawdocs such
ctsoowneoofproperty whobuildsrs Improvee thereon,.nil
whence Laws fnrauch projects with econuecmr(s)licenud pursuant the Conannorx ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Lew.
❑ I am exempt under,Sm. ,B&P C for this rcawn OUTSIDEFEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Ow. Dam DRAINS-F100R,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby alErm that l have a cenifiewe ofconsem to self-insure,or a certificate of RECHIPI'a
Workers Compensation lnsumarom ra cenified copy thereof(Sm.3g0.Lab C.)which FIXTURES-PER TRA PARK FEE Y N
covers.11 employee's underthis pewit. GAS-IA.SYSTEMAN us BUILDING
CI Polly# BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM- VE PLANCHECK FEE
❑ Carolled copy is hereby famished.
❑ CeriGed copy is filed with the city inspection division. GREASEIINDUSTRL W,41E INAIr
5W11 GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS WE
COMPENSATION INSURANCE
(This section reed not becompleam ifthe pe.it is fmanehundred dollars($10b) SEWER-SANITARY-ST ENERGY FEE
orless.)
I certify than in the performance ofthe work for which this Permit is issued,l shall WATER HEATER W/VENT/ELE
not employ any person m any moaner so as to became subject a sbe Workers' PAID
Coon'tcaionuovsof C.1iforom. Data WATER SYSTEMIGIRATINGfi
Date RtteiplM
Q Z Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. ik
Vf become subject to the Wasters Compensation Provisions of the Lothar Code,you must
� ; foMwith comply with such provisions m this permit shill he deemed revoked. BUILDING FEE
W SEISMIC FEE CONSTRUCTION LENDING AGENCYUZ I starchy efRrm Net there ie a conswctian lending agency fm the performance ofO the work for which this permit is issued(Sec.309],Civ.CJ ELECTRIC FEE
0 U Lenders Name
lenders Address QTY �y,` MECHANICAL PERMIT FEE '. PLUMBING FEE
U 1 cemfy Nm 1 have read this application and sum that the above information m MECHANICAL.FEE
caws I agree to comply with all city and county ordinances atM state laws reducing to PERMIT ISSUANCE J
U z buildingcanswction,.ndherebyautMdmupreunwivesofthisciry wentesupenthe CONSTRUCTION TAX
above-meadma d property for inspection purposes. ALTER OR ADD TO MECH.
a (W agree to save,indemnify and keep harmless the City of Cupertino against
liabilit s,tolhonts,cmm and expenses which may inany weyaccrueogalnt said City AIRHANDLINGUNIT(TO 10,"CFM)
in con q nee of the granting of th
2R. AIR HANDLING UNIT(OVER 10,000 CFM)
g of Applicant/Canwcmr Dam EXHAUST 110013 W/DUC ) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dote Receipt.
( Will the applicant or future building mcupant store or hurdle haearehom material BEATING UNIT(OVER 100,000 BTU) TO
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,SmOon 25532(a)] VENTILATION PAN(SINGLE RESID)
do
❑Yet ❑No
ISSUANCE AT
Will the applicant orfmure building occupant nu equipment or devices whichemit BOILER-COW(311P OR 10.000 BTU) (Y
havN..a air conn,rams as defined by.the Bay Arse Air Quality Management BOILER-COW(OVER I(at"BTU) I!'#
D1McR
h
C3 yet 11 No NEW RESIDENTIAL MECH. SQ.FT. 29 �akA(�
I have read the lo,Coe.Sections requirements under Chapter understand
of the SES ag� 99a4�
Cali(, ha HealthSa tSnfety Cod,Sections 255,5,25533and 25$30.1ter 6.9of that SEP t
if the building dors not currently have a mount,that it is my responsibility to notify the Cx N\
occupant of the requirements which must he met prim to muaae of a Certificate of �1.1'y ser I/ur
Occupancy. 11 �}-/�
Owner or amhomedagent Dam T ISSUED BY;: ` t���/�/���/l
OFF[