27384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEU I RICA L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION 27384
BUILDING ADDRESS: e���-� �/J1/� SANITARY NO. APPLICATIONSUBMITTALDAIT
�IUNIT# LOT#
OWNF PHONE: CO CTOR'SNAM LIC NO: 4
W 114 " G /FS TC S6 NIC CONTROL#
�A CIII'IECT/IiNGIN.:R: LIC NO: AD1, e-si�Q6 S k� 95- S'
CONT^ACT—:_— PHONE: fJ'
,Ik//� �� �Z/ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
e ke 1 BLDG ELECT PLUMB MECfi
PERMIT ISSUANCE R Ire—
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL LJ L�
GKZ I hereby affirm that l am licensed under provisinnsm Chaper9(commencing with JOB DESCRIPTION
4100 Section 700(1 Division 3ofthe Business and Professinne Coamind my license is in PANELS
c U full farce and ef�fect/'� ((� ^LGL f G
La.,Zsu Liccnx Coss CLQ fico.# l J e UPT02MAMPS
"i<;:, Dam Camaracmr 201-I010 AMPS
ZOyZ A CHIMCT'SD CL RA ON OVER Io00AM1'S SQ. .FLOOR AREA $/SQ.FT.
O Z—❑ 1 understand my plans shall be used m public mcords.
QmF-W , SIGNS ELECTRICAL
�d�j Licensed Professional
C y al¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Ne. 1 hereby afEmt that 1 am exempt from the Contractor's License Law for the
4134.y following ream..(Second]031.5.Business and Professions Cale:Anycitymmunty TEMP.METER OR POLE INST.
which res,fires a permit to construct,altar,improve,demolish.or repair any suunure
Q
7 prior toils issuance•also requires the applicant forxuit
chpermm filensigned.amemem POWER DEVICES
W
.<0 that an is licensed pars......he provisinos of the Contractor's License Law(Chapter
a Xp� 9(commencing with Section 7")of Division 3ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
ly_y or Nat he iseaanpt therefrom and the basic for the alleged exemption.Any smatterer
i-•ZQ Section]031.5 by any applicant for a permit subjects the applicanuu a civil penalty of OUTLETS-SWITCHES-FIXTURES
5!�Q not on,than five hundred dollar,($50)).
al ❑ I.mownerofthepmpeny,ormyemploymswimwages theirsolecmmpensaoon, NEW RESIDENTIAL ELEM. FT. STORIES TYPE CONSTRUCTION
x3222 will bOlimuark.and thestrumum isnot inm.dedmlaffered for mle(Sm.JW4,Business
and Professions Code:The Contrecml's License Law dos not apply m an owner of
property whobuildsorimproves thereon,and whodnesxuch work an selforthtnug),his
employees,providedrm
hat such imommucntsom not intendedoro(fiend Inside.If. OCC,GROUP RES.UNI'f5
however,the building or improvement is sold within one yearn ersmpletion,themwner-
builder will have the burden of moving thin he did not build or improve for pon,we of T L
ml,)
❑ 1•as owner of thepicpcny.am exclusivelycomoveling with licensed contmmasm QTY. PLUMBIN ,BERMI1C .1 FEE FLOOD ZONE APN
construct the pmimt(Sec.7(Pl Business and Professions Cale:)The Contrxmrs AN
License Lawdocmot apply manownerePropeny who buildsorimPploves thereon,and CE 3 ,1
who contractsforsuch projects with a contractions)licensed pursuant n the Contractors ALTER-DRAIN AT
L'muse Law' FEE SUMMARY
❑ l.m exempt under So. ,B&P C for this reason KI OUTSIDE FEES
SANITARY Y
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION ' RA SiFL ,A U. SCHOOL TAX y ry
❑ Ihemby affirm thatihaveacenifi<tete ofcoraem mxlf-insum.mamaifimmof
[%S`-P•R RECEIPT
00 Wmkeri Compenmtion Insurance mamnificd copy Nertof(Sec.3800,Lab C.)which • Q PARK IEE Y N
covers Poli,.111employ 0 L•) G ;A. .40171 PTS V J RECG p
Cnmy'�9 p� r BUII TNG UI SION FEE$
�Ccnified copy is hereby famished T AS EA.SYSTEM-OVER
-. PLANCHECK FEE
❑ Cenified copy is filed with the city inspection division. f$ ` GRPwt V_SDUSMR WASTE,INTERCEPFOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' •Xi GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section aced not he completed ifthe permit is(armee hundred dollars(SIM) SEWER-S -STORM EA.2MI7. ENP
m less.)
I certify that in the perfomanceof the work for which this permit is issued.)shall WAR 1 RW/VENT/HLECIR
not employ any person in any manner so as to become subject to the Workers'
PAID
Compensation laws of Califomia. Dam W STEM/1'RFATING
tJ z Applicant D� Receipt
z C) NOTICE TO APPLICANT:ILaftcr making this Cenificam of Exemption,you should NEWR' ENTIAL PLMB, SQ.ET. TOTAL:
F' ^ become subject to the Worker's Compensation previsions of the Labor Code,you must
foMwith mal with such provisions or this permit shall be deemed mvokmL BUILDING E
Q CONSTRUCTION LENDING AGENCY SEISMIC 1
ZF
z i hereby affirm that the.is a construction leadingageney for the performance of
U O the work for which this permit is issued(Sm.309],Civ.C.) TOTAL: ELECTRI E
finders Name
ULender's Address QTY, MECHANICAL PERMIT FEE PLUMBING
I certify that I have read this application and state that the above information is
come[. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
E-' h building construction,and hereby authorise representatives ofthis city to enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgments.costs and expenses which may in any wayzccom againstsaid City AIR HANDLING UNIT(TO 10,"CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I0,0M CPM)
Stgnmure of Appficom/Cmaracmr Date EKHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(In 100,000 BTU) Date Recn t#
Will the applicant or future building nampern 11.11 or handle lesardeas mmmod
as defined by the Coleman Municipal Cale.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,1IIXI BTU) T TAL:
Cade.Section 25532(a)]
❑Yes 15No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 1BB,EW BTU) ISSUANCE DAT
Will Otappllcummares m building by But
equipmentunlit Management 16 a,
hazarAmm 0<wmminanu m defrted by Nc BaY Area Air Quality Management BOILER-COMP(OVER JKLOD0 BTU)
DistrictP — / �Y
❑Yes W7J NEW RISIUENTIAL MECH. $G,FT. R
1 have read the harardous materials regmremcros under Chapter 6.95 of Ne /s}T.�hY �99�
California Heads&Safety Cada Sectiova 25505,25533 and 25534. 1 understand that ka F/
ifthe buildi gd nal curently l) t n ihatil' myresponsibilitymm ifythe
acupum f Isom „f ore1 a rl p' mis
since.1 a Certificate of Lurrjy/
3-/sem S
Dillfier or JuN t Dam TOTAU ISSUED BY:
OFFICE