27044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BU DINCADpRF�S SANITARY NO, APPLICATION SUBMITTAL DATE
11 UNITA I I LOT#
OWNE S NAME: PHS`
5�4ftih -/ O/". NIC CONTROL#
RCHITECT/ENGINEER: LICNO: AD RE ❑
Co PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
Oy�JBLDG ELECT PLUMB
PERMIT ISSUANCE
LICE SED CONTRACTOR'S DECLARATION ❑ ❑
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION_
(hereby affirm//////������atlam li nsed underprmis'pnsofChapter9(commencing with ///��I lRIIPPTION/J
a 0 fSci 11 iom 7000)m[ o M1 Business and�rQfe slo license is In PANELS -�'1'✓1YI ///
4 runfmmeand rf l.lF
'yz License 1 s IAe.# UP T0200 AMPS
ti=y Dam Contractor 201-IIXp AMPS
z�NT�, ARCHITECT'S DEC OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z 4O 1 understand my plans shall be used as public records.
P4� W SIGNS ELECTRICAL -
g�2� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUFDMISC.
O y F I hereby affirm tM1at I am exempt from the Contractor's License Law for the
W 3 w0 m following reason.(Section 7031.5.Business end Professions Cade:Any city or county TEMP.METER OR POLE INST.
y which requires a permit to cornua,alien improve,demolish,or repair any snuclure
i pno, a.issmance,als.unpues the applicant far such permit to file.signednammem POWER DEVICES
AO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
dap ' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC 99�VVAALUA
,may or that he isexempt therefromunit the basis for theullegedexemption.Any violationof OUTLETS-SWITCHES-FIXTURES I NRo
Section 7031.51, any npplmant fora permit subjects the applicant too civil penalty of VV
t more than five hundred dollars($500).
n❑ 1,asownerofthepmprty,ormyemployeeswithwagesastheirsolecompensadon, NEWRPSIDENTIALELECB _SQ.FT. STORIES TYPECONSTRUCTION
LBS- will do the work,and the structure isnot intendedorofferedforsale(Sea 7044,Business
and Professions Code:The Carl...mr'a License Law does not apply ro an owner of
property whobuiidsorimprovesthemon,andwhodoessuchwork himselfouthrough his
own employees,providardthat such improvemeatsare not intendetoroffnedforsale.If, I GROUP RES.UNITS
however,the buildingor improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the bathe.of proving that he did ran build or improve for purpose of
sale.),
❑ I,as ownerof the pmpeny.amexdusively cono-aaing with licensedcontracmrs to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the inflect(See.7044,Business and Professions Code:)The CentimetersLicense Law does notapply to an ow.a,.fp,.,n,who builds orimproves thereon,and PERMIT ISSUANCE
who cans,,Law.raw.for such projects with econvactor(s)licensed pursuanuh
a the Contractor ALTER-GRAIN&VENT-WATEREA FEE SUMMARY
Lime sa ( 7
❑nI an exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICEOUT ID PEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y L
N
I hereby affirm that l have a certificate ofconsentto self-inane,or a certificate of R EI
incia' a n n{{m�{{`` c thereof(Se c.3800,Lab C)which FIXTURES-PER TRAP PARK FEE
covers all m ryytfem ti� RECEIPT#
VVVVVV GAS-PA.SYSTEM-1 INCA OIITLBTS
Policy# BUI NG DIVISION Flili
Company GAS-EA.SYSTEM-OVF.R4(EA) PLANCHECK
❑ ifed copy is ere y umisheI
t ertified copy is Rled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING E
CERTIFICAI'EOPEXEMPTION FROM WORKERS' GREASETRAP SOILS E
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forma,hundred dollars($100)
or less.) SEWER-SANITARY-STORM EA.200FT. P&RGY FEE
I certify that in the performance.fthe work for whichhis permit is issued.I AM] WATER HEATER WAENT/ELECTR
not employ any person in any m as to become subject to the Workers' PAID
Compensation Laws of California. Dam so WATER SYSTEMRREATINGcel #
C) Z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
.moibecome subject to Ne Worker's Compensation provisions of the Labor Code,you most
•••"`���� ' forthwith comply with such provisions or this permit shall he deemed revoked. BhLDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISM( E
VZ I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRICF
0 the work for which this permit is issued(Sec.3097,Civ.CJ
IL r, Lenders Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
V 1 andly that I have read this application and state that the above information is MECHANICAL PEE '3
1, correct.l agree comply with all city and county ordinances and smite laws relating to PERMIT ISSUANCE
cl� building consvm ,a dhereby amthorim representatives of thio city memerupon Ne CONSTRUCTION TAX
L) 7, above-mention, p p or inspection purposes. ALTERORADDTOMECIi.
(We)ag m i demnify and keep M1armless the City of upertiggqqqq against
liabilities,judg ant. is ad expenses which may in any way aCCm e�nlsaid City AIR HANDLINGUNIT(TO 10,000CFM)
rconsequare oft ant of this PermitII 1I``
AIR HANDLING UNIT(OVER 10,000 CFM)
Signnmre ofA tic t o rector pate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000M ✓ Date Receipt#
Will the applicant or future building occupant store or handle hazardous muterial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety 'HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(n)7
El Yes El No VENTILATION PAN(SINGLE RPSID)
ISSUANCE DATE
Willthea licanmrr'murebuildln BOILER-COME(3HP OR 100,000 BTU)
pp goy the Day Area it Quality Management
P A
zardnus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
sric[1
❑Yes ❑No NEW RESIDENTIAL MMIL SQ.PC
I have read the hazardous materials requirements under Chapter 6.95 of the NOV 10 1994
Califnceia Health&Safety Code,Sections 25505,25533 and 25534.I understand that /.
if,he building does not currently have a tenant that it is my responsibility to notify the CII Ib
OF Vvi-CT1111wo
occupant of the o F it mens which mus[be me[prior to issuance of a Certificate of
Occupancy. cC
Owner or authorized agent Data TOTAL: ISSUEDBY: SA A�J
OFFICE
r