27857 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMB NnoNO PERMIT NO.
NG-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICAI DON 27857
(WILDING ADDRESS: SANITARY NO. APPLICATI/ONNSUBMITI'ALDATE
O� TN IAT#
.. 'BSN P C T ACTOR'S NAME: LIC NO: (/
Y a a L C N/C COMI'ROL p
RCUHr iCANGINEER: LIC NO: VDRESS: ❑
O U CA
'ONfAC'L PHONc
RMIT F88 BUILDING PERMIT INFO
BLECfRIQ HE
wok' PER n`ISSUANCE
. BLDG_ Fy PLUMBMAl
PERMIT ISSUANCE �Lfyl(`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
coliz I hereby affirm that l an licensed underprovisions of Chapter9(commencing,with •, ,1pRpESC ION
{900E Section 7(100)of Division 3 ofine Business and Professions Cade,and my license is in PANELS 1 \`/
t�UU full forc.mdeffem
<Z License Class Lic.# UPTO200A
y 6 Dam Conn. 201-I ODO AMPS
ZOt`ti,� ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.FLOOR AREA 5/SQ.FT.
O Z I understand my plans she be used as public records.
y
SIGNS ELECTRICAL
<y , Licensed Prolloomml
�prtiQ OWNER-BUILDER DECLARATION SPECIAL CIRCUTUMISC.
1 hereby effort that I can exempt from the Contractors License Law for the
(x131'-m fullowing restum.(Soon.7031.5,Business and Rofessioru Codi:Any city.,county TEMP.METER OR IDLE INST.
1=�I Om j which requires a permit to concoct,aheq improve,demolish,or repair any strucmrc
E YE pd.,to its issuunce,alsa dotter theapplicam forsmin permit..fileasignedsmmrnnt POWER DEVICES
C G C that he is licerued pursuant to the provisions of the Contractors License Law(Chapter
a.ao� 9(carramong with Section 3ofthe Business and Profession Code) SWIMMING POOL ELECTRIC
mVALUATION
,-y or that he is exemptthcmfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Y
Section 703).5 by any applicant for a permit subjects the applicant to s civil penalty of
G m more than five hundred dallam($500).
mC3I,esownerofthepropeny,ormyemployeeswithwagesnthcirmlecompenad.n, NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCTION
Is. will dothework,and the sracmrcis not immdedor offered foraale(Sec.7044,Business
and professions Cade:no Contractors License Law does not apply to an owner of
propertywhobeltmina,uses ftwo.,and b.dceamchwork himselforttooughhls OCC.GROUP RES.UNITS
ownemployees,proviJedthatauchimpmvemen3=mtintendMoroffe forsde.If,
however,the building c rimprovement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sale.).
❑ I,asownerofthepmpeny.ame.clusivelyamnactingwithlicenmdcantrciomm QTY. PLUMBINGPERMIT FEE FLOODZONE APN
comma the project(Sec.7044,Business and presidium;Cale:)The Conn..'.
LiceneLaw does not apply no onownermpon mrywho builds or improvestherem,and PERMITISSUANCC
who mmunsfor such projects with acontracmr(s)licensed li muem mthe Contra .DR &V -WATER EA
Licame Law. ENT' ( ) FEE SUMMARY
❑ lam exc_mpt under Sec. ,B&PCfor this re OUTSI
O EVICE SANITARY YDN
Owner Date Iss a F4n•t ler. SCHOOLTAX YECEIPI'N N
WORKMAN COMPENSATION.foo DECLARATION �s VV�r IV
❑ cm'C offirmthat lhave acenlfcenifiMo ythe f(Sm.rc,orU c.;c R� 0.ECEIPTp
covers a'C.mpcnsationlnsumnm dracenified copy thermf(Sec.38W.LabCJ 8^ u11 PARK FEC Y N
.vera ell employees under this permit. '•e! 0e •1, RECEIPTN
Policy M e1 1, fij BUILDING DIVISION FEES
Company w!,
❑ Cenificdcopy is hereby famished. T1Jhkiih
PLANCHECK FEE
❑ Cenifiedcopy is Bled
wit marity inspection division. coW 9WIM&ITE INTERCEPTOR GRADING FEE
CERTEFICATE OF EXEMPTION FROM WORKERS' Pe SOILS FEF.
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollan($100) .R-S ITARY-STOR A. ENERGY FEE
or leu)
I certifythn in the perfarmanee of the work for which this pcmtit is issued, WA rR
nor employ any person in any member so as to becane mbjttt on the Workers' PAID
Z Companmtion TawseCalifornia. Dam WATER SYSTEMIM NC Date Receipt If
Applicantlb,
zO 0 NOTICE TO APPUCANT:If,after making this Certificate of Exemption,youOKU TOTAL:
!-+ p_J bccomesu ecttothe Workers Compenadonprowboominthe Labor Code,you must
R' f.mwith comply with such provisions or this permit hall M1e deemed revoked aft Is
BUILDING FEC
LT-) 5 CONSTRUCTION LENDING AGENCY • SEISMIC FEE
Z 1 hereby affirm Ilan there is construction lending agency for the performance of
U work TOTAL: ELECTRIC FEE
O the fns which tins rdt is penis i (Sec.309
issued(S . ],Civ.CJ
{2. ,r Lenders Nome
U PLUMBING FEE
Lender.Address QTY. MECHANICAL PERMIT FEE U 1 certify that E have read this application and sato that the above mfonnnion is
0. correct. I agree to comply with all city and county ordinances and stats lows minting an PERMIT ISSUANCE MECHANICAL FEE
(� building contructum.and hmebyeothoriu represenmdvioethi,oily m onto,upon the CONSTRUCTION TAX
U a
7 Mve-mentioned pipe for hopes, n purposes. ALTER OR ADD TO MF.CH.
F7
(Wo)agree to ,Inde If keep hamtlus the City of Cupertino against
liendhies,judgme s man mass which InVin any way accrue against said City AIR HANDLING UNIT(TO In,"CFM)
inconsequence .granflorN
AIR HANDLING UNIT(OVER 10.000 CFM)
tle,21tt-11
ppliced/tAlonst., IData EXHAUST HOOD(W/DUC17
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100.000 BTU) Dale 0.eceiptM
Will the applicant m fumrc h tilding mcupznt sire m handle hi ardour mnerial
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER UK,"BTU) L:
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
AM i Willdwapplicant orfuturebuildingcecupantuseequipmm.tordevioeswhichemit BOILER-COMP(3HPOR 100.W0 BTU)
hazardous yr contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER UK,"BTU)
District? 1:1u EI A O D
YNo NEW RESIDENTIAL MECtI. SQ.FT.
r I have read the haredous m nieces requirements under Chapter,6.95 of the
if'he
built.,
.,dhffiSafetymo ent,haveatnce,thatitis myoombi and25334.1it,mendtat MAR 221995t�
ifthfflona Health
Seely Cade.
Setotons 25505, 5isand 25534.1 tytostandify the �—�/
mcupan of the requirements whig must be met prior to issuance of a Certificate of
Gempa..Y. CITY Ur I' I
Owner or edsmod.gem Date TOTAL: ISSUED BY:
0 ICE-