27039 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIIIDPTC-F.LECTRICAIPERMITNO. 27039
1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. / 7 O 3 9
BUILDING PROJECT HIRING IFICA'T']ON
L
BUILDING D ESS: - SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT It �`
O\V FlONE: //� ONTRA ( E: .IC O: 7
1
IN/ N/C CON]ROLa
ARCH['I ECT/ENGINEER: LIC NO: A D ❑
CDN' PHONE: 3, "' a BUILDING PERMIT INFO
'ELECTRIC PERMIT FEE
BLDG ELECT PLUMB ECH
PERMITISSUANCE
LIC SEDCONIRACTOR'S DECLARATION AppL1ANCES-RFSIDENTW, TOB DESCk1 N '. .N
o9z Unebyaffirmt ntlamlicensd underprovisionsafCTapmr9(cnmmencingwith ' 1
�u00 Semion7000)of on3ofthc Busincaa and first sC dray license is in PANELS w
UE rullfarce and of c.cc..��11 UP 1'O 200 AMPS
pa.,ZW License Cliy�s—V —Lic.p
.<0-vi Imo �1 1/1 Cnmrucl201-IOW AMPS
Z OvNiE �s/'7rt 7�7!' Aj RCI II'ITiCan,DEC[[DOVER["AMPS SO,IT.FLOOR AREA S/SQ.FI'.
O z ere, l undermund my,lims shall he used as public records.
SIGNS ELECTRICAL
Q Licensed Professional
WKK OWNER-Beard(,m Ile ORATION SPECIAL CIRCUIT/MISC.
1 hereby affirm,,(Sethat I am exempr from me Coition,ra License law for Ne
�3tz-vt following,earn.(Section 703 1.5,Business and Professions Codr.Any airy or caunry TEMP.METER OR POLE MST.
1— 03 which requires a permit to Washmit,eller,improve,demolish,or repair any structure
999, N� prior to its issuance,also requires the applicant for such penrdto file a signed statement POWER DEVICES
ly q O that he is licensed pursuanuo the provisions of the Convector',License Co.(Chapter
L p,o 9(commencing with Section 71X%1)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC /VVALLUUATIQ
iW^y nnhtnheiexempt therefrom and the basis for the alleged exemption.Any violation of OUTLEfS-SWITCHES-FIXTURES
QSec tion 7031.51, any n„lican,far a pewit subjects the applicant I()a civil penalty of JOO I 1
not marc than Bve hundred dollars(S500).
u0.tsT�� m [II,ovnwneroHheproperty,nrmyemployeeswim wagesestheirsolecompensntion, NEWRESIDENTIALELECTR _SQ.ET. STORIES TYPE CONSTRUCTION
p,3— will dome work,and the structure is nonnandedorofferd for rale(Sca.7044.Basines,
and Professions Code:The Cnntrumn/s License law docs not apply an an owner of
Property whobuildsorimprovexthemon,and whodoessuch work himrelfot throughhis OCC.GROUP - RI•S.UNITg
own employees,consideration such impmvemenrserenot immndedcroffered forrale If,
however the building or improvement is sold withinmre yemofcampletion,theowner-
builder will havethe burden of that he did not build or improve for a of TOTAL:
proving p purpose
ale.).
❑ I,us nwnerofthe propcny,amexclusivelyconuaming wiNlicensedcommctors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lmmstct the project(Sec.7044,Business and Professions Code:)'Ile Connector's
icense Law does not m ty anowneraramin whobuildsorimpnoven maroon,and PERMITISSUANCE,
who contracts for such projects with acmmrstoron licensed pursuant n the Contractor's
License law. ALTER (PA) FE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
:.
SANITARY YN
Owner Date RECEIPT N
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,EDGE,AREA,COND. SCHOOLTAX Y N
❑ Ihereby affirm that l have aceniGcam ofcommntsovelf-inure,oracotGficateof RECEIPTN
FIXTURES-PER TRAP
Workcrs'Compensationl u q]�,)7 fQ�6�/ 3800.Lab C.)which PARK FEE Y N_
mvcrsallemplit, sun VIFI Ir re .SYSIF.M-I INC.4OUTLETS RECEIPT,
Policy N BUILDING DIVISION FEES
Cotapan GAS-EA. 'YSTHM-OVER4(EA) PLANCHECK PER
❑ rtifid copy ash b umist d.
Cartilicd
copy
is filed wiW the city in.pectinn dNiii GREASE/IND 'T RUWASTEINTP.RCEPTOR GRADING FEE
CERTIFICATEOFIIKEMPION OMWORKERS' GREASETRAP SOILS FEE
COMPENSATION 1 URANCE
Ofissesdanneedambecompletdifth permitisforonehommuldo ( SEWER Y- ORMEA.200FT. ENERGY FEU
or less.)
lccrif,datintheperformanceofth workforwhichthis prmnitisass II TBI�IIhA ENT/F1ECTR
not employ any person in any m a as m become sub&t to ken PAID
Z Compensation Lnwsof Califamia. Date SYS /TREATING Date herseif,0
Applicant
NOTICH'I'0 APPLICANT:IL after making I on n.you eh NEW% ENTIAI,PLMB. SQ.IT. TOTAL:
hecrmealainat 1.the Worker'a Comparison.,prostate-miles
i ode,you
� , forthwith comply with such Provisions or this permit shaledecm ed. BUILDING PEE
L21 (] CONSTRUCTION LENDING AGENCY re SEISMIC FEE
z Ihereby affrto that there is a mnstruaion lending agency far the perfnmt TOTAL: ELECTRIC FEEU C) the work for which this permit is issued(Seo.3097,Civ.CJ
Lender's Name
lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �.
0 U 1 certify that 1 have read this application and auto that the above information Is
7” 4 correct. I agree to comply with dl city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingconsuuction,and hereby amhotize representatives clads city to enter upon the ICONSTRUCTION TAX
U ^j abow-mentioned property for inspection parliament. ALTER OR ADD TO MECH.
F7
(We) arca arse,inti ify and keep hnrmleas me City of Cupertino against
Iiahilhicx,judg a,'costs In su whicheay'Inany way accttami, iat said ity AIR HANDLING UNIT(TO HL"CFM)
sonw,ticncc tit grant, , t is noir.
AIR HANDLING UNIT(OVER 10,0(10 CFM)
Sigrimmoof Ap wnOCont mr Date EXHAUST HOOD(W/DUCD PAID
IIAZAR I/5 AIERIAIS DISCLOSURE HEATING UNIT(TO Rai BTI!) Dem Receipt It
Will the applicant or fund ing occupant or handle heurdoua material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the I Ruth and Safety HEATING UNIT(OVER 100,000 BTU) TAE:
Code,Section 25532(a)1 VENTILATION PAN(SINGLE RfSID) �-
❑Yes ❑No
L6
BOILER- ISSUANCE DATE
Will scar contaminants
minrftuure defir d by them ay Ana
Quality Management
COMP(711FOR IW,OW BTU) P A '
District?air cumaminunts xs deltoid by the Bey Arca Air Quality Management - 'BOILER-COMP(OVHR 100,000 BTU)
District? .�I
❑Yes 11 No NEW RESIDENTIALMECIeqI. SQ.FT. MAR 9 1995
I[save read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sartain,25505,25533 and 25534.1 understand that it
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if the building does not currently have amount,that it is my responsibility to notify the CITY Uf whEkfINO
accupnm of the requirements which must be met prior to issuance of a CeniBcme of
,Rcupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE—,,