27639 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1'IfTN('-RL1!(:TRI A' PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MEI"., NICAI. 27639
BUILDING PROJECT IDEN'OFICA-1'[ON
B 'l1.DING ADDRESS: CA
SANITARY NO. AVPLITION SUBMII'fAl DATE
UNIT# LOT# a
O 17RS N M` Pit OM (_]12:5 NA & LIC NO
�' bi A• TG/'�1 N/C CO HOLM
RCIIITFCf/ENGINEHR: LIC NO: .SR __py-- Q r"l. - V/I (-/ ❑
CONTACT: PHONE: $W+.:f$,mq Z'wn�' - '
QTY.It.is y`hCLECTRICPERMIT' FEC BUILDING PERMIT INFO
E";" t BLDG ELECT PLUMB MECH
PERMITISSUANCE [
LICENSED CONTRACTOR'S DECLARA'I ION APPLIANCES-RESIDENTIAL
0%z I hcrebyaffrm that l am licensed under provisionsofChapmr9(commencing with LOB DESCRIPTION
�00 Senian7 )of Division 3 of the Business and Professions Cod,and my license is in PANELS
tyU� fullfameandelTen, -
I<.Zm License Class Lic.p UPTO200AMPS -
rn<0Dam Cautranm 201-I"AMPS
,ZO=NZ ARCIiiTECT'S DECLARATION OVER 1000AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
02—p I understand my plans shell be used as m
public cords.
F N�J SIGNS ELECTRICAL
-� Licensed Professional
��'V OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
u I hereby aftim that I am exempt from the Contractor's License Lew for the
W 3 a
to rollowing mason.(Section 7031.5.Business and Professions Cade:My city or county TEMP.METER OR POLE INST.
I"E:0yg which rtquiresepcnnit tv constmct.elmr.improve,dcmolish,mmpa'v.try atmcttue
>M pnormits issuance,nLsn requircathe applicant for such pemtiuo file eeigneJ statement POWER DEVICES
<0 that ht,is l teensed pursuant to the provisions of the Convectors License Lnw(Chopter
aaAre 9(commencin with Section 7000 fDivisibn 3 ofthe Business and Professions Code SWIMMING POOL ELECTRIC
X�W (commencing )a ) VALUATION
W) 2, or that he is exempt mcmfmm and the basis for the alleged exemption.Any vioNtionof OIITLEI'S-SWITCtI[S-FI%TLRC$
ItZ> Section 703 Lapplicant 5 by any applicant for a permit subjects me applicano a civil paraeyo(
M< wt transport five hundred dollvs($500).
�'$$ y y py egesustheirnolecompensation, NEW RESIDENTIALELECfR _SQ.FT.
p ❑ Lmownk,an thestructue is ti Io eawimw STORIES TYPF.CONSTRUCTION
L will domctimix Cat: he Comisnotimendreas Law
a.,aply.J044,Business
and Professions ldym The Commcmis License Lew docs not apply if an owner of
properly whobuilNorimprovesmerton,and whodoessuch work himxlfm through his - OCC GROUP EUNIT�l
own employees,provided thatsuch improverrcroarenot itaendedoruffered forsale.If,however,the building or improvement is sold within one year ofcompletion,theowner-
builder will have the burden of that he did not build f ins rove for f TOTAL:
proving p puryoseaale).❑ I,esownaroftheproperty,amexcluaivelycomractingwinslicensedcomracmnm QTY, PLUMBING PER IT FF.E FLOOD ZONEN
construct the project(Sce.7144,Business end Professions Cade)The Cammctor's -
LieenseLaw does not apply Wan owner nfpropertywho builds or improves thereon,end 'ITERMIT ISSUANCE
.Wear uten forsuch projects width contractor(.)licensed ptirstanna to the Contracmr's �qEy-DRAIN&VEedT-WATER(RAN
License Law. / (' FEE SUMMARY
❑ 1 ant exempt under Sec. ,B&P C for this reas6n BACK Fl. W M .DEVICE SANITARY Y D N
Owner Onm DRAINS-F\ OOIt,ARF?A D. RECEIFJ#
WORKMANCOMPfiNSATIONDECIARATION SCHOOL TAX V N
❑ Ihertby affim that ihave eanificete of conxm to ulGinsure,ora an
am of FIXT I RnRAP RF.CEIF'Tp
Wmketi Compensation lnsumnce orecenifedeapy thertof(See.]g00,IabCJ icb PARK FEF. YN
covers all employee's under this permit. A.SYSTEM-I C UfLETS RECEIPT#
Poliey# BUILDING DIVISION FEES
Company -EA.S TF.MO (FA) PLANCIICCK FEG
❑ Certified copy is hereby faernMed.
❑ Cenifed copy is filM with the city inspection division. G t n LWASTEI RCEPTOR GRADING FEE
CER'I'IPICATE OPEXEMPTION FROM WORKERS' GRF SWI RAP SOILS HE
COMPHNSATIONINSURANCE
(Ihissecrian neednot he completed ifthe petrit is Toren hundred doll.($II10) 5 ER-SANITARY-S RM F.A.200FT. ENERGY FEE
or less.)
I certify that in the performance of me work for which this permit is issued,I shall WA 'R IuEvFERW ?NOELECI'R
not employ any person in any manner an m to become rect m the Workers PAID
Z Compensation Lawsof Califomia. Data WATF. SYS HEATING . Date Receipt#
C O Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.f§'. 'OTAL:
LO) become subject to the Worker's Compensation provisions or the Labor Code,you must
5 forthwith empty with such provisions or this permit shall be deemed revoked. BUILDINGFIRE
aCONSTRUCIONLENDINGAGENCY SMSN ' E
U2 I hereby affirm that thepem is a construction lending agency for the performance of TOTAL: ELE .E
O the work for which this chair is issued(Sar.3197,Cis.CJ
4L Lender's Name PLUMB '
lender's Address QTY. MECHANICAL PERMIT PTE
U 1 cenify that 1 have mad this application and state that me above infrnmanioa is
r1' PWatorenanti county I agree to comply with all city acounty ordinances and state laws relatingto PERMIT ISSUANCE MECHANIC/ITS
to huilding construction,and hereby authorize representatives ofthis city to enter upon the CONSnEU TIONTAX
U aNwo-mentioned property for inspection papoose, ALTER OR ADD TO MHCH.
(We)agree tat one,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costsandexpenxs whichmaymany way scerue against said City AIR HANDLING UNIT(TO Mash CrM)
in co m'mmosa t rantingof flys �
/ AIR HANDLING UNIT(OVER IO,fNq CPM)
7 AQ I
Signammo Applica Cann vr� Dam EXHAUST HOIJD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
W ill the applicant or future building accupmu state or handle hazardous material
as defined by the Cupctino Mmouripal Code,Chapter 9.12,and the Health trod Safety HEATING UNI'r(OVER 100,000 BT'U) 'TOTAL:
Cade,Section 25532Ie)1
❑Yes ❑No VENTILATION FAN(SINGLE RFSID)
9SUA ATE
Will meapplicmmorfumrebuilding occupum yui
uxcepm Much emit BOfLF.R-COME(311P OR 100,d(10 BTU)
DfruIW 1
It Will
air conrammorms as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.OW BTU)
icR JAN 19
❑Ya ❑No NEW RESIDENTIAL MECH. SQ.Ff. yv 199 '
I have read the hazardous materials requirements under Chapter 6.95 of the l#�'�'r Ur• C 4
Celifomia rlealm&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tempt,that it is my respe rdbiliry to notify me V Urr`N
meuWm of the Wchnnerants which must be met Has to issuance of a Certificate of
Occupancy.
Owner or aumorized agent Date TOTAL: ISSUED BY '