27085 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DUAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
85
BUILDING AD�fR�S �I Uj�� ,—S SANITARY NO. ACP.P�LICATION SUBMITTAL DATE
( "l.. U LOT 'C/J L —�V [-
OWNERSNAME: p ; 1i4aO `%AMJk'E�{: /F /yy`/ IC NOO: •,rag
NIC CONTROL#
ARCHITECT/E (NEER: V\ IC ADORES : ' 8 O4 V /IN VA El
CONTACT: PHONE: QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG E� PLUMB MUCH
( PERMIT ISSUANCE �y�1 `pyo.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL- 1 TOB DESCRIPTION❑ ❑
ps2 Ihcreby afErtnthatl 3mlicensed Buinssand Professions
Code, (commencing with
004 z Section 90IXB of Division 3 of the Business and Professions Code,and my license is in pANpq,$
W{z full ftmo and effect. 4
QQ Leiria
Li1.0 Q� ,,{� UP TO 200 AMPS
mQy Dole Comracmr r 201-11100AMPg
Z O-,4 ARCHITECTS DECLARATI N OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—C I understand my plans shall ber used as public records.
1=4 W SIGNS ELECTRICAL
Licensed Professional
� nn
OWNERUUILDER DECLARATION SPECIAL CIRCUIT/MISC. ��e[(I b'
Oyu I hereby affirm that I son exempt from the Contractors License Law for the
oO yar following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP,METER OR POLE MST.
V1 m J which requires a permit to consumer,alter,improve,demolish,or repair any swcmre
N>,� photo its issuance,also requires the applicant for such Permitm file a signed statement POWER DEVICES
W OO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
as 9(commencin with Section 7"of 3ofthe Business and Professions Code SWIMMINGPOGLELECTRIC
o Seal )o ) VALUA/TI�ON
Irxl`—r'm or thatSectio 7031.empt therefrom and the becopermit subjeasegedexemption.Anyviolaid of UTLET'S-SWITCHES-FIXTURES U C! CJ l
t. Q no,mea Tn31.5 by any dreddapplicant llfor$perch subjects the applicant aeivll penalty of J 3
not more than five hundred dollars(E500). NEW RESIDENTIAL ELECTR S .FT.
mom, m ❑ Lasownernfdmicattimmon land rhlnyeeewhhcand missileir sole compensation, Q l'ORIBS TYPE CONSTRUCTION
y will do thewons and the ha CmIranm'sLice se awdoes not (Sec.9044,Business
and Professions Code:The Contractor's License Lew does not apply to an owner of
ds
ownerywhob,pmor ediba"shhimpmvements notintend oroffeorthrsWe.Is
wnemployees,provided tharauch improvememsarenohimendaloroffemd tarsale.If, OCC GROUP RES.UNITS
however,the building mimprovement is sold within one yesrafcompletian,the owner- TOTAL: �)
builder will have the burden of proving that he did nor build or improve for purpose of
sole).
❑ I,as ownerofthe property,am exclusively contracting with licensed contactors to QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the projam(Sec.9094,Business and professions Code;)The commetor's
License Law does not apply to an owner ofproperty who builds or improves thereon,and PERMIT ISSUANCE
who commas Por such projects with.commucmr(s)Iiwnsed posuanno the Contractor's ALTER TER PA PHH SUMMARY
License Law. ( )
❑ T am exempt under Sec. ,B&P C for this reason BACK PLOW PROTEC EV OUTS D E
Owner Date R SANITARY Y N
RECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,A
SCHOOL'1'AX Y N
I hereby❑ ers'Compareamthmnhave a rance or certificate elcopycreatiothen f(Sesure,Or Lab C.)which
RECEIPT#
FIXTURES-PER TRAP
Worker%Compensehinn Insurance or ecenifiedc�py thereof(See.3800,Lab CJ which PARK FEE Y N
covers all employee's under this Permit. GAS-EA.SYSTEM- INC.4 0 RECEIPT N
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4HA) PLANCHECKME („3p
❑ Certified copy ishereby famished.
❑ Certified entry is filed with Ne city inspection division. GREASBIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('this section card marine completed lithe permit is foromehundrN dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that I.fie perfamtance of the work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any mama,so aar to)ygarpe=diecdlo the Workers PAID
Q �, Campensatimuffaws Of Celifpmir��latr� - f! Pe, WATER SYSTEM/PREATING Date Receipt#
Applicant U NS'lili(,T�
z NOTICEF PPELT�afmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL: b
t-0 h become subject to the Worker's Compensation provisions of the Labor Cade,you mus[
!lYi ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE .DZI
CONSTRUCTION LENDING AGENCY SEISMIC FEE y
z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
V O the work for which this permit is issued(Sec.3099,Civ.CJ #
[2r lender's Name
p U Lenderres
Leader's Adds QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is
(Ta correct.Iagree to armply with all city and county ordinances and shoe laws relating to PERMITISSUANCE MECHANICAL FEE
F^ p" building construction,and hereby authonm represenctives.phis city to enter upon the
above-memloned mer for ins f CONSTRUCTION TAX
(j 7 t p y pec mai purposes. ALTER OR ADD TO MECH.
G le j agree nt save,indemnify and keep harmless the City of Cupertino against
Inam,, judgments,cosv dexpenses which may in any weye[cme against said City AIR HANDLING UNIT(TO 10,000 CFM)
m ce of theg of this rtnit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si re try Applicao/Cons or Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10(1,(100 BTU) Dare Receipt#
Will the applicant or future building Occupant store or handle hazardous matenal HEATING UNIT(OVER 100,000 BTU) TOTAL: 3r
as defined by the Cupertino Municipal Code,Chapter 9.12,said the Health and Safety
Code,Section Vast .)? ❑No
C1 Vast VENTILATION FAN(SINGLE RE.SID)
ISSUANCE DATE
Willuseequipmenmdevice,whichemh BOILER-COMP(311P OR IOQOOn BTU)
'Y n
Extraction,air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) i"'k J W
District?
❑Yes ❑No NEW RESIDENTIAL,MECH.—SQ.FT.
1 have herd the hazardous materials requirements under Chapter 6.95 of the SEP 3 0 1994
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not cur ally have a®nam,that it is my responsibility in notify the
mct'CIS 1414014140oupenh of the requirements which must be met prior to issuance of o Certificate of
Occupancy. LII I VI" 4U
Ownar or authorized agent Data TOTAL: ISSUED BY: • D�V�`
OFFICE