27075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I1IfDnVf P.L., R PERMIT NO.
PtN -MNCIANICAL
PURcrETIEN
27075 O C
BUILDING DIVISION APPLICATION/PERMIT F7777777NUNOP1
IFICATION
BUILDING ADDRESS: SANITARY NO. APPLI T^IO11NSSUBMITTALDAIE
WUNIT# LOTH / / A
OWNERS AME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROLL
T s
ARCHHECT/ENGINEER: LIC NO: ADDRESS: _V
V�45WNJ ��L �
- CONTACT: PHONE: Qom. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 108 DESCRIPTION
Mai Hurchydfnn that l oro licensed tnderpmocconsof Chepter9(commencingwiN
0100 Section 90(07.(Division 3 of the Business and Professions Code,and my license is in PANELS
FCU toll force and flat. �rJ_o�
F W
Lice n Wes LicA J V UP TO 2W AMPS I Tg �G�
y= ate Cmuoactor 201-1000 AMPS {�\
ZOyz RCHI I EC S DECLARATION OVER I100AMP5 SQ.FT.FLOOR AREA $/SQ.FT.
O Z—C I understood my Plans shell he used as public secords.
SIGNS ELECTRICAL
Licensed professional
Q
OWNER BUILDER DECLARATION SPECIAL CURCUR/MISC.
m'O y G I hereby affirm Net 1 em exempt from the Confiscator License Law for Ne
tsl'30.y following remen.(Section 1031.5,Business and Professions Code:Anycityorcounty TEMP.METER OR POLE MST.
F LL o,¢ which requires a permit to comtruat,alms,Improve,demolish,or minor any structure
}� prior to its issuance,also requires the applicant for such permit to his a signed statement POWER DEVICES
p that be is licensed pursuant to the provisions of Ne Contmemes License Lew(Chapter
YXo 9(commencing with Section 1000)of Division Sof the Business and profession.Code) SWIMMING POOL ELECTRIC VALUATION
WMo, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%T'URES
FZa Section 7031.5 by tiny applicant for a Permit subjects the applicant to a civil penalty of
t more than live hundred dollars($500).
NEW RESIDENTIAL ELECTR 5 .PT.
m n❑ I,usnwnerufthepmpcny,ormyemployeeawith wagesus theirsolecompensatlon. Q STORIES TYPE CONSTRUCTION
will do the work,and The structure is not intended or offered for sale(Sec. Business
and Professions Code:The Contmcmt's License Lew does not apply to an owner of
properly whabuilds orimprovas theman,and whodoes such work himselforthrough his OCC.GROUP RES.UNITS
ownemployees, novided that suchimprovemems menotimendedoroffered ficume.If,
however,the buildingor improvement is sold within one yeerofcompletion,theowner- TOTAL:
builder will have The burden of moving Net he did not build or improve for purpose of
ars'.).
❑ I,ns oconesoftheptopenyamexclusivelycontr¢ting with liavedconnmmnto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
corewct the project(Sec.1014,Business and Professions Code:)The Commuter PERMIT ISSUANCE
License Lew does not apply to an owner m properly who bui Ids or improves thcmon,and
whocentmcm fursuch projects with acontractoni licansed pursuanua the Convectors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y—N
—
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
CIIhemhy nffrm that have acertifcate of consenuoselLins....or.cenificatti RECE pTp
pens. FIXTURES-PER TRAP
Wnrken.'Com tion Insurance ar ecenified copy thereof(Sec.]tlW,Lab C.)whicM1 PARK FEE Y
covers all employee's under this permit. GAS-EA.SYSTEM-1 IN rLETS /• RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM- ER 4 THAT PLANCHECK FEE
❑ Cenifted copy is hereby fomiahed.
❑ Certified copy is filed with The city inspection division. GREASEWNDUST WASTE INTF.RC OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
(This section need not ba completed ifthe permit is for one hundred dollars(SIDE) SEWER- AHOARY-STO F.A.200 . ENERGY FEE
or less.)
I certify that in The performance ofthe work Por which this permit is issued,I shall W HEATER
not employ my person in any mnuter so m to become,subject to the Workers' PAID
Compenmtionlaweof Califrmie. Due WATEVY I Data Receipt#
0z Applicant
NOTICE TO APPLICANT.If,der making this CcAfcam of Exemption,you should NEW R A Q.FL TOTAL:
tibecome subject to Ne Worke(sCompetnnlon pmvithrnof Ne Libor Cade,you must
a ' forthwith comply with such provisions or this permit shell he deemed asserted. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affmi that there is a construction lending agency for the performance of
the work for which this t is issued(Sec,3097,Co.C.) ELECTRIC FEE
O inn
0 L) Lender's Name
Lender's Add.. QTY. MECIIAM AL PERMIT FEE PLUNKING FEE
L) 1 certify that I have mad Nis application and mute That the above.w.slain;is MECHANICAL FEE
correct.lagmemcnmplY withyaracity andcouny oomismesand stem hste rthtingm PERMIT ISS L -
U' Z building-mentronedti recarr frinspectioizerepmsenlaYvaof thiocitynmmr upon the CONSTRUCTIONTAX
V z above-mentioned pmperry for inspection and purposes. ALTER OR ADD TO MEC(I.
(We)agree m oven indemnify end keep harmless Ns my of Cupertino against
liebilities.judgmmu,coma eMexpenses whichmey inmywiy acme gdnxt dCiry AIR HANDLING UNIT(TO IB,B00 CFM)
r
cnnuquence t egr ting Niap4 A R HANDLING UN T(OVER 10,000 CFM)
go mm of Applicm mtnctor oro EXHAUST HOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the the Cupertinom or a icipal Code,Cng ant aorto,and the
humorousmaterialSafety HEATING UNIT(OVER I W,BIXI BTU) 0
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heuph roti Safety
Calc,Section 25532(u71
11 Yes ID No VENTILATION VAN(SINGLE BESID)
ISSUANCE DATE
Will bcupplicantnrfuwmbuildingoccupam useequipmem or Jeviceswhtcherrit BOILER-COMP(311P OR 100,001)BTU)
huzuduus air contuminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 11
District'( pi
❑Ycs ❑No NEW RESIDENTIAL MGCH. SQ.FT. 190I have mad the hazardous materials requimments under Chapter 6.95 of The 2 7 199
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
Hthe building does not currently have a tenant.cast it is my reaponsibiliry m notify Ne
osccupam of the segoirtments which must be met prior m issumcc of o Cenifiwte of
Occupmcy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE