27663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BTIfLUTNfrEEECTRTCA. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MSCI IANICA I. 27663
NUILUING DIVISION BUILDING PROJECI'l DEN'I'IIICA'I ION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUIMITI'ALDATE
_TM r / IINI'r# LOT If �1 �i a
OWNI3 NAM PHONE: CONTRACTOR'S NAME: LIC NO: N/C I C/O `NT1tOLp
ARC[II I ECT/ENGINEER: LIC NO: ADD RE S; ❑
CONTACT': _ PHONE: '" BUILDING PERMIT INFO
�# / QTY. ELEC' IC'PERMIT 'FEE
JA /
M E.�MIL'+ —�ap�� PERMIT ISSUANCE BLDG ELECT UMB MECfI
LICENSEDCONTRACTOR'S DECLARATION ❑ ❑ ❑
APPLIANCES-RESIDENTIAL LOB DESCRIPTION
4)"Z 0 1 hereby affirm that l amlicensed under and
limomaofChapter and mmeneIng with
�SOO Sectionorceand of Division 3of Ne Bainaaend Profeuiom Code,end mylicemeuin ppNEl,g
full force and effect.
¢ZW Licrnu Cl}p Licp S�6 UP T02lM1AMPSal
y�y Dete_` Contactor .ln -� ✓fh�f 201-I"AMPS
Z Tm
Oy 7�. ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PI'.FLOOR AREA E/SQ.IT,
OZ^Appp Ian mendmy plans��'—ty�� atedespahlicrecoNa. _
<Z4 �/i z,�(f�& SIGNS ELECTRICAL
Q,� Lic A fcssiunal
LC OWNER-BUILDERm the
ntrION SPECIAL CIRCUIT/MISC.
Ebcrehy n.(Se that I am exempt from the Cosigns Co License Lew for the
m 3Om
following rcamn.(Seaioa'/031.5,Businessiand mprove.deme Coale:Any city or county TEMP.METER OR PoLE INST.
ocimmich yuircxapennittoconswet,,licimforsudemMistofilepsigned.tterni
Kw QC) that hes issuance,arsuntto t sthevisios of the Contioch mitto Liease La (Chapter PoWER DEVICES
tyY�Oz thin he is licensed pursuant to the provisions of the ComrecOors License law(Chapter
0. oLL OO
9(commcncing with Secuon]0(X)of Division 7af the Business and Professions Cmtle) SWIMMING POOL ELECTRIC Ile LU/AT�ION
yxf r^y or that he is exempt therefrom and the baisfor the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES ' /]
E.2 G Section]031.5 by any applicant fan permit iati the applicant..civil El of \/
5 z^ nte t mathan five hundred dollars($50X). nalf
ckl 1 � ❑ I,asowneroftheMNny,ormycmPloyeeswithwagesasthei(soleeompettsadon, NEW RCSIDENTLILELECIB —SQ,FT. RSr* TYPECONSTRUCION
1 will do the work,and the stractumis not intended nroffmad fn nsfe Sec.]04q Business \
and Professions Code:The Conrmeor's Liana Law Nes not apply to an owner of
- property whobuildsorimpmvestbereon,and whodoes such work himselforthrough his
own employces,prnvided 0hatuch improvements..at imardedmintimissile.ssile.If. OCC.GR RES.UNITS
I.. the buildingorimprovement issold withinoneyearofcompletion,the owner.
buil der will have t he harden mfnovin that he did not hui Id or ire for u 'f0'TAL:
I g prove purpose of
sea.).
❑
I,aowncrofthepropeny,am exclusively cnmrening wiNlicensal rontrecmam Q6Y. PLUMBING PERMIT PEE FLO DZONF. APN
construct the project(Sec.7044;Business nad Professions CWe:)The Contractor's PERMIT ISSUANCE
License Lew doesnot apply manowmcrof property who buildsorimprovea thereon,and
who contracts forsuch projects with acummemr(s)licensed pursutor.0te Commemr's ALTER (FA)License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE SANITARY Y DEFE N
Owner Data DRAINS-FLOOR,ROOF, COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION , . SCHOOLTAX Y - N
I hereby affirm thin I have a ceniftoam of conseano self-insutn,or a cenificom of ,�.� RECEIPT st
FIXTURES-PER TRAP
mkeri Cmmpensmion Insurance orecertifiescopy 0hercof(See.3800,Lab C.)which PARK FET•. YN
ever,all amployee's nmdtt this permit.- GAS-EA.SYSTEM-I INCA OUTLETS RECEIPT#
Policy If BUILDING DIVISION FEES
Company _ GAS-IIA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division., GREASIpINDUSTRL WASTE INTERCEN OR GRADING PER
CERTIFICATE OF OMPENSATION ON RAN WORKERS' GRIgSETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not 4completed iHhe permit is for ona hundreddollem(g100) SEWER-SANITARY-STORM PA.200Ir1', ENERGY FEE
or Ras.) a�
I verify that in Ne puforrrwnce ofthe work for which this permit is issues,Ishan d WAI FA W/VENT/ELECTR
not employ any permit in any manner so as to become subject to the WorkerPAID
Compcminmi swsof Califomla. Data ATER SY .M/TREATING Dam Receipt#
0 O Applicant
NOT ICE TO APPLICANT:If,after making this Contrition of Exemption,you should N11"RSIDENTIAL PLAB. SQ.FI'. TOTAL:
F� In became subject o the Workers Compensation provisions ofthe Labor Code,you must
�i forthwith comply with such provisions at permit shall he deemed revoked. BUILDING Fill!
W �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby arm that a hem is construction lending agency for the Performance of
U O affirm
the work for which this Permit is issued(Sec.3097,Civ.CJ ELECTRIC ITE
I..t Lender's Name
O
U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I vanity that 1 have road his tiPp[icetiom and nate that he all infr madun is
}' 4 cored. Iagree to"reply with all city arta county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL IPE
I--' building connmctionand httebyautbodu teptelamufivoaofthis city memttupon the CONSTRUCTION TAX
V z above-menti ed ympeny for inspection parliament. MINGLE
OR ADDTO MECH.
We) m save,indemnify and keep harmlaa the City of Cupcnino e
liabilities Jgrannis,costs end exarrarsw ' yinony w^y accrues ainn saiNDLING UNIT(TO 10,01it
in cons once of the gmndng o is pert
NDLING UNIT(OVERIO,IXpCFM)
met arc of Applicunt/Contmc toS'flI000(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSUREG UNIT(TO 100,000 BTU) Date Receipt#Will the applicant or future building occupant fare or handle haardaus mG UNIT(OVER I W.IX1B BTU) T
a defined by the Cupertino Municipal Cane,Chapter 9.12.and the Health and CNe,get9i❑Ya32(a)? ❑No ATION FAN(SINGLE.RI+SID)
Will the applicant minicar building oucupanmse equiPon"m ordevices which emit
BOILER-COMP ODE OR 100,000 BTU) ISSUANCE DATE
Intonations air contaminants a defines by the Bay Area Air Quality Managemem BOILER-COMP(OVER 100,000 BTU) ,pq�
•
District?
❑ P A/V I J
Yee ❑No NEW RESIDENTIAL MECH. SQ.PI'.
I have read the hamrdmus materials rcyuiremena under Chapter 695 of the ha��
Culifnmia l iwith&Safety Code,Sections 25505,25573 and 25534. 1 underetand thin
f Nc hal frog docs nm cutrcmly hevm s tcnant.lhnt it is my res onsibility m mairy the I
occupant of the requirements which must be mot prior to Issuance of o Cenificale of
OccuClpancy. V1
NUOwner or amharired agent Data TOTAL: ISSUED BY:
OFFICE