27810 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I H-DING-ELECTRICAL FERMI"r NO. /��J 810
APPLICATION/PERMIT PLUMB INO-MECHANICAL.
BUIBUILDING DIVISION
BUILDING PROJECT IDENDF-ICAI'ION' L 1l
BUI.DING ADDRESS: /J SANITARY NO. APPLICATIONSOBMIITALDATE
/ 9420 �f—ST«Q /�R'� UNIT# LOT#
U NE S NAME: PHONE: ACTOR'S NAME: LIC NO:
L E'71 e q2p /eaSC� to wT S-3/ 9 /S NPU CONI ROL#
VyIITECI'/ENGINEER: LIC NO: A DRESS:
7 KL 7 853 /Z zo r4sr t,4,J ;Do 2- ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Cn2
p CEs S gyp 0 7 -Q&y aLQG EL PLUMB MECH
PERMIT ISSUANCE s. TL��- ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION ppPLIANCES-RESIDENTIAL
FJO2 Iherehy aff irmthml amlicensed under provisions of Chapterode, (it mmmm�se with G TOR DES tIPf ON ie
cad Scell..andof Division Jnf the Business and Professions Cale,and my license is in ppryFLS a/f�.J`
y V full forte and effect.
FZw License Class Lie.# UP TO3W AMPS
F v¢OiG Date—Contractor—ARCHITECTS DECLARATION 201-lOW AMPS SQ,Pp,;11P
E/SQ.FT.
Z O N a I understand m I hall be used as public records. OVER 1000 AMPS
OZ—O YPansa
F_Fw SIGNS ELE L
�pdJ Licensed Professional
y�Q OWNER-BUILDER DECLARATION SPECIA IRCUIT/MISC.
O c. I hereby of f m that I am exempt from the Contractor's License law for Ne
w3wm following mason.(Section 703 1.5.Business and Professions Code:Any city or county IEMP. ETER OR POLE INST.
which requires a permit m consumer,.]air.improve.demolish,of repair any aVucntrc
C�QF prior to its issuance,also requires the applicant for such prmat to file a signed statement POWER EVICES
w W�O that be is licensed pursuant to the provisions of the Com onsura License law(Chapter
dXo'x 9(commencing with Section 7")of Division 3 ofthe Bovine - fessions Code) SWIMMI POOL EL17C'IRIC N
w—vs or that he is exempt therefrom anal basis for the all se "am. ny violatfon.f flXIVR[S
F'La Section]II3L5byanyapplicantfmrapennits theapplicamtoa ivil penalty.( OUTLET'S- WITCHES- 7 ��� � not morc;han rive hundred dollars($5
❑ Lasowncrofthepropery,o employees with wagcsaxtheirsol,c npcnsmion, NEW RESIDN AL ELECTR _SQ.IT. RTYPE.CONSTRUCr10N
will do the work,and the nmimendcdoroffcredferaalc(Sa.] ,Basin.
and Professions Code: a Contactors License law does nor apply r.o o r of
pmperywhobuildsorim avec lherennandwh.daessuchwnrkhimulfonh nughhis
hoemployees,providedt arauchimpmvemems Item doroffsmd fo ala,If, OCC GRES.UNITS
weveclheballding.rim a mem is sold within o e) f letion,the w
builder will have the book, fpnivingthathe 'd improve for put neof
sale.). m r
❑ Lasownc,ifthepmpeD .n
Ding with licensed c r. QTY. PLUMBING PERMIT FEE ROOD LONIi APN
nsruct the poijccl(Sec.7 4men Professions Cock:) ..fee,
License Lpm
awdoe,amaplymowac,.f raywbo build,.,i esdannot.and PERMITISSUANCE
whaconbnem fur such projects w bacon , a)licensed Pu. mmlhe Commemrs
Lonme Low. ALTER WATER((EA)
FEE SUMMARY
❑ I nm exempt under Sec. B&P C for this anon BACK FLOW PROTECT.DEVICE OU"r SIDE FEES
SANITARY Y N
�Owner De¢ DRAINS-FLOOR.ROOF.AREA.COND. RECEIPI'p
WORKMAN COMPF:N NDECRATION LASCHOOL TAX Y N
❑ Ihercby affirm thmlhave acerifcam of content msdf-imine.orneertifcate.f
MIXTURES-PER TRAP RECEIPT
Wmketi C.mpensmiun lmumnceorncenifiW wpy thereo[(See 3AW.Lob CJ which PARK FEE Y N
rsallemployce,ruiderdOspermit. l GAS-EA.SYSTEM.I INC.40UTLFTS RECEI B
Company
HUIL ING DIV 1 NFEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished. 1
❑ Cenifed copy is filed with thc,:ily inspection division GRE,NSIhnNDUSTRL WASTE,INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS IT
COMPENSATION INSURANCE
(Thissection need not he completed ifthe permit is garner,hundred k.11ars($I W) SEWER-SANITARY-STORM EA.20O19'. Fry
or less.)
I certify that in the peHmmance f,ha week far which his permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ nay Person in any mnrntn so.to become subject m the Workers' PAID
Compcmetionl.awsof Caligomia. Dam /I
WATER SYSTEMREATING
z D' Rcceiplk
Applicant
z 0 NOrICE TO APPLICANT:If,after making this Certificate of Exemption.you shouldNEW RESIDENTIAL PLMB. SQ,PT.
L•-' TOTAL:
V) become subject (lie Worker's Compensation provisions or the Labor Code,you must
forthwith comply with such provisions Or this permit shall la,deemed revoked. BUILDIN EE 'r
p„ Q CONSTRUCTION LENDING AGENCY SEISMIC E
Z I hereby of ion that there is a construction]ending agency for the performance of
Up the work for which this pe.i,is issued(Sce.)H9],Civ.C.) TOTAL: ELECTR CFEE
lender's Name
U.
U Lenders Address QTY. MECHANICAL PERMIT FEE PLUM NO FEE
1
in that 1 have read ria appliciam.and amte that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISS DANCE MECH ]CAL FEE
building construction.and hereby authorize reprcsemtaivesof this city no enter upon the
V 2 abOvcmentioned pmpery for inspection purposes. ALTER OR ADD TO MECIL CONST"R`CDON TAX
(We)agree in save,indemnify and keep harmless the City of Cupemino against
harbilitics.judgmemo,casmand expenses which may in my way income againslsuiidd City AIR HANDLING UNIT ITO 10,"CFM)
ce
in aromequenthe g!9!!!
go is permit. 3 /L /S
ll AIR HANDLING UNIT(OVER 10.000 CFM)
Signaof Applicant/bmissr Date EXHAUST HOOD(W/IIUCD
PAID
IIAZ RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,"BTU) Dam Reccita#
Will the applicam or future building occupant same or handle hazardous material
as def tied by i he Cupertino M unicipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM."BTU) Awn
Code,Section 25532(a)1
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,"BTU) ISSUA CED TE
Will se npplica ircen,as
by do, ay equipment orality which emit
IarmO? air c.maminen1 as defined by the Bay Area Air Quality Managemcm BOILER IW,WO BTU)
District? .(
13 Yes 11 NO NEWRESIDENTIALMECH. SQ.FT. Cly 199
I
have alta the Safety
all materials 5505,255 3 under Chapter 995 of the L/(- (,•UrrU `�
if
uillkaltb&Safety Code,Sections
on,that
it is and 25534. ]understand than
if Incbuildingdrawsnot currently have ast he et itis myauance of
to notify the
Occupant of the requirements which must he met prior m issuance of a Certificate of
Occupancy.
Owner in,authorize].gem Date
TOTAL: ISSUED BY:
OFFICE