27633 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO to"'Hh57-LT.1.1rIMA PERMIT NO.
APPLICATION/PERMIT PING PROO-YIECHNTIFIC 27633
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /�/yJ( SANITARY NO. APPLICATION SUBMfITAL DATE.
lleI3 ✓//�.7UNIT# LOT
0xsvNERS AME: PHONE: CO FACTOR' NAME: LI NO: N/C CONTROL#
�ARCHI'fEC'fIENGINF.i:R: LIC NO: AD �S: 'r�9 ID
CONTACT: PHONE,: C/ L#F!
QTY. ELECTRIC PERMIT FEE BUILDING PE INFO
BLDG ___ELECT PLUMB MI[CH
PERMIT ISSUANCE 1:1 ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
�KZ Iherchyaffirmthat l am licensed underprovlslons ofChapter9 parnmencingwith
s�J00h�-� Section 1000)of Division3ofthc Business
.and
",,Professions Code.and my license is in PANELS
�It, fu 11 forceand tAbcl.1� Lic.p — `�,Jv� UP T0200 AMPS
FZm LicenseClasslV/OO�- .r,s
to<y Date BGG—Cnmructnr Qf[_ 1/�Q 201-1000 AMPS
ZOO,,z a � _�•y ARCHITECTS DECLARATION SQ.FT.FLOOR AREA E/SQ.FT.
OZ_e I understand my plans shall be used as public records. OVER 1000AMPS
SIGNS ELECTRICAL
Licensed Professional
�yD'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUFDMISC.
KOiO I hereby affirm at I am exempt from the Contrsema's License Law for the
3
way following reason.(Section 7031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INST.
which"mics a Permit to construct,alter,improve,demolish,or repair any srmeture
5g�}zto its issuance,also thea licant for such Permit file a sighed dstatement POWER DEVICES
prior equires PP pe gnc
K p O that he is licensed pursuant o the previsions of the Contractors License law(Chapter
9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F
Z Q Section 1031.5 by any applicant for a permit subjects the applica t to a civil penalty of
�Sn< not marc than five hundred doll ars(8500). NEW RESIDENTIAL ELECTR _SQ.FT.
W[=,,, ❑ I.asownemfthepmpeny,ormyemployeeswithwagamtheirwlecomprn .n. STORIES TYPE CONSTRUCTION
#3222 will do the work.and the structure is not intended moffered formic(Sec.1044.Business
and Professions Cale:The Commcmen License Law does not apply to an owner of
popertywhobuildaorimperves N examrand whodeassuch work himselfor Juough his
ownemployces,providedthal nuchimprovementvumnotintendedomffemdformle.If, OCC.GROUP RPS.UNITS
however.the building or improvement is sold within ma,mrofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lasowneufthepropeny,amexclusivelycuntractingwiNOcenwdconuactorato QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onstruet the project(Sec.]BM,Business and Professions Cade:)The Contractor's
License lawdoes outsell anowncrof,rapeny who builds or improvestherson,and PERMIT ISSUANCE
who contracts forsuch projects with aemlraatma)licensed pursuant to the Contractors ALTER-DRAIN&VFJJ'T-WATER G)
License law. (' FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PRO'T ECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPf N
cove
FIXTURDRAINSES
S-PER
ft,R f.AREA. U.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑
Workers'
affix that)havece ora ccamodcopy tttose(Soc.3,0f Lab C.) hi of FIXTURES-PER AP RECEIPT#
Wnrkeri Compensntirn Insurance oracenifiedcnpy thereof(Sec.3glq,Lab C.)which GAS-EA.gYS .k1-I INC.40UTLETS PARK FEL Y N
rs all epnplgvg�;Jyndn46i�p�iJ, -/� RECEIPT p
Policy# LLaa//!l�iHH dd //JJ`/ BUILDINGRECEIPT
#FEES
C�— lctaybed co�+ rs U GAS-EA.SY M-OVER 4(EA) LANCHECK FEE
py is hereby famished.
Apy is fled with the city inspection division. GREASEYIN USTRI.WASTE INTER
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE AP ' SOILS FEF.
COMPENSATION INSURANCE
(Tis section need not be completed if Ne permit is before hundred dollars(JI100) SEWP -SANITARY-STO EA20g1 . ENERGY ITE
or less.)
I certify that in the menrms,of the work fm which this permit is issued,Ishall W ER HEATER WNEiI. CTR
not employ any person in any manner in as to become subject m the Workers' PAID
z Cmmpeasation laws of California. Dam &AMRSYSTEVRONG Date Receipt#
Applicant
O NOTICE TO APPLICANT,If,neer,making this CeniEcate of Exemption.you should NEW RESIDENT .Mg. SQ.Ff. 'TOTAL:
become,subject to the Workers Compensation provisions ofthe Labor Gale,you meat
> forthwith comply with such provisions or Nis peril shall be deemed revoked. BUILDING FEE
CW., D CONSTRUCTION LENDING AGENCY SEISMIC ME
7 Z Ihereby affix that them is a commustion lending agency for the perforanc<of
the work for which this t ed X..3099,Civ.C.) TOTAL: ELECTRIC FEE
U O pcmti is sew
Lender's Name PLUMBING E
U FELcmler.Address QTY. MECHANICAL PE IT FEE
I certify that I have read this application and state that the above inforadnn is
cori l agree to comply with all city and county ordinances and state laws strong to PERMIT ISSUANCE MECHANICAL WE
F' buildingcrnaVuc er.and henhymthisi n:pteamnaliveso(this city to crtsruprnvhe CONSTRUCf10N TAX
V z abom
ve- entioned poH.
verty for inspection purposes. ALTER OR ADD TO MEC
(We)agree to save,indemnify it keep harmless the City of Cupertino against
lami k dddrrdggggggmens,costs and expenses which may in any way memeagainst said City AIR HANDLING UNIT(TO IR"CFM)
mrantin8o is peril. .
/ -g/57AIR HANDLING UNIT(OVER 10,000 CFM)
Si m > of A
gnsairsiol AppliegUsCmilipfir Date EXHAUSTHOODQV/DUC)
PAID
HAZARDOUS MAT12RIALS DISCLOSURE HEATING UNIT GO 100,0011 BTU) Date Receipt#
Will the applic t or future building occupant a tom ser handle humorous mamnal
m HEATING UNIT(OVER 1W,000 BTU) L:
defined by the Cupertino Code,Chapter 9.12,and the Health and Safety
Gita Section 25532(up
13 Yes 11f'N/ VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR R10,000 BTU) ISSI/(s aN�CE DATE
Will the epplicam orfutouch goccupanmxequipmemordevic<swhichemit wt ^
h vnd n t reed by the Buy Area Air Quality Management gO1LER-COMP(OVF.R IW.WU BTU)
Di.striclla air am roman,as J
❑Yes No NEW RESIDENTIAL MECH. SQ.IT. U 08 19
9,5
have read he hazardous..am.],m9uiamords under Chapter 695 of the } 95
California I health&Safety Code,Sections 25505,25533 and 25534. I understand that
ifthebuil ' s not mmmdyh veamnant,thatit is my rtsponsibiliry to notify the I�� UF Gws;
tap# the ngnhe ens w nun be met print m is.,a nee of a ceyrcatc t ,�
Occu a
Owne n a t n ized a nn Date TOTAL: ISSUED BY:
OFFICE /