27294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO L 1 -LLNU R AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /�
BUILDING PROJECT'I DEMI'IFICATION T
BUILDING ADDRESS: /,(/y[I /A� �II II SANITARY NO. APPLICATIONSUBMITTALDATE
`I"I�+1�� MDEIT LOT# �1
OWNERS NAME: `av ♦ J: C CfOR'g N E LIC : N/C CONTROL'
al
bt
RCHIIEC1'/ENGINEER: LIC NO: AT"Q duesn`` st— ❑
Lrr
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PER INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ Ib# F-1 rz
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
CIZZ I henbyuffiem than l am licumadunderpisi
mvonsof Chapter9omm
(cencing with
o�oa(4l cuOWWV,�p_F. Section]000)of Division 3.f me Business and Prefessii...Cde,e
ond my license is in PANELSfia �yT ,I
FLW Lilcn Cies,to.and fat.C_ao Lm# �0�'('L/a)�s UP T0200AMP5 /1�µ/
ro?y Date Contrxsor 201-1000 ANN7~O,Z. ARCHITECT'S DECLARATION OVER IUOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ln—CZ-0 1 underatund my plans shell armed as public recuNs.
F Nt!� Licensed Professional SIGNS ELECTRICAL
94P OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
k3 f I hereby tiff Ihas 1 am exempt firm the Commcmis License law for the
u1 m following mason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE NST.
♦h ecO a which sequins a permit to convict,alter,improve,demolish,or repair any ameture
Mm}� prior to iu iaxumce,idsoraquires the applicant for such permit o file esigned situationPOWER DEVICES
pj A C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencing with Section 9010)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W M,,, omhat he is exempt therefrom and the heads for the alleged exemption.Any violation of OUTLETS-SWITCHES-Fl%TURES
F. a Section 90315 by any applicant for a permit subjects the applicant o a civil penalty of '[V
^� not more than five hundred dollan($500). NEW RFSIDFNTIALELEM SQ.PT.
W � ❑ I,mowrmrofNepropettyormycmployaawith wegesutheirsolecompemaun, STORIES TYPECONSTRUCDON
a will do the work,and the stmctumis not inteadetoroffemd for sale(See.7144.Business
and Pmfessions Code:The Contractor's Lamar Law does not apply to an owner of
own employees,
provided
improvements
onotintwdedorofferedforealhhis OCC.GROUP RES.UNITS
ownemployees,pingorimposuchimpis sold within
ne yearro oornplfered the owner-
sale.).
however,she have
the
Wrimpro.mein is sold within one yam or improve for
-the owner- o
builder will hove the harden of proving that he did not build or improve for purpose of
le.).
❑ I,asowncrofthe propetly,emexclosivelyconanning wire liaved conwnorsm QTY-. PLUMBING PERMIT FEE FLooD ZON APN
^manct the project(Sec.70,FL Business and Profeaiafu Code)The Contractor's PERMIT ISSUANCE
License Lew does not appy loan ownerofproperty whobt iIdaorimproves thereon,and
who contracts fmsuch pmi withacourcter )licensedpumumuoshe Cion.wes
License Law. ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this maannBACK PLOW PROTECT.DEVICE SIDI:FF.F,
SANITARY Y N
Owner Data pftplNS-FLOOR,ftOOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby off tbetlhav<ecertificam of consrnno mlf-inmm,on ceni0cnm of RECEIPT#
/ FIXTURES-PER TRAP
Wnrkers'Compensmion Insurance orucertified copy thereof(See.3900,Lab C.)which PARK FEE YN
covers ellemplayee's under thix permiLal 100 q/ � D GAS-EA.SYS'TEM-I INC.4 OUTLETS RECEIPT.
Policy. IIVV o{ 7J6 .O BUILDING DIVISION FEES
C^ any GAS-PA.SYSTEM-OVER4 TEA) PLANCHECK FEE
.i Cer ifed copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASR/WDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hecampleted ifthe permit is forone hundred dollars($IN) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify that in the performance ofthe warkfor which this pemdt is issued,I shall WATER HEATER W/VFNTOI
/ELEC
nut eropley any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califamia. Date WATER SYSTEMfrREATING Dam Receipt#
O Z Applicam
7 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMBI Q.FT. TOTAL:
E: U) become subject rush, Compensation provismancifthe Labor Code,you most
�i , forthwith comply with such provision or this permit shell be domed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that is a construction lending agency for the perfmmana of
The work for which this permit is issued(Sec.3197,Civ.CJ 12!:TAII ELECTRIC FEE
U O Leaders Name
C) F' Lender's Address QTY. MECH CALP MIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and stem that the above information is
UJ correct.l agree in comply with all city surd money ordinances and state laws misting to PERMIT ISSUANCE MECHANICAL.FEE
building construction,and hereby authorize representatives of this city to an upon th< CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)aims I.save,indemnify and keep hamtlese the City of Cupertino against
Iiabilitles,judgment,costs and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO IQOW CFM)
in cmoormence of the gmming of this gamut.
AIR HANDLING UNIT(OVER 10,W CFM)
Signatumof Appliam4Contmctor Data EXHAUST HOOD(WMUM)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Data Receipt#
Will the applmmt an future building occupant store or handle M1uzmdous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health toHEATING UNIT(OVER IW,000 BTU)Safety TOTAL:
Code,Section 25532(u)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
TI
BOILER-COMP PHP OR I W,M BTU)3He ISSUANCE DA
Will
rs air comma icate rebuilding by the Bay equipmentQualit cesanagemech nt PAID
hvallous air mntaminmu n defined by the Bey Area Air Quality Management BOILER-COMP(OVER IN,"BTU)
istrict?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. JUL a
1 1 have mad the hazardous materials mquitements under Chapter 6.95 of the 1995
California Health&Safety Code,Sections 25505,M533 and 25534. 1 understand that
if the building docs not currently be.a mount.drat it is my Hoponsibiliy to notify she CITY Ur sur[
occupant of be myviremenN which must be met prior to issuance of a Certificate of H 1 INU
Dc'tPeracy
Owner of swhorizesl agent Data ISSUED BY:
OFFICE