27234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-F,LEUIRICAL PERMIT NO. sr
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 4
BUILDING PROJECT'IDENTTFICA'rlON
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMf'IT/AL DATE
Lt LOT#
WNERS ME: PHONE: O TRACT'gt'SN E: J I.IC NO:
ec.F6-RAM -f5 !] AJ S CHs iu--T1 1K N/C CONTROL#
ARCH]IECT/ENGINEER: LIC NO: -�J D �,VS—S::Agg5a nen CC
4H�
CONTACT': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
. BLDG ELELTP MECH
PERMIT ISSUANCE 1:1 El DMB ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
amz I hereby affvmthail am licensed underpmvisions of Chapter9(commencingwilh
ta100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
Fa UE fuclef amid eRec �g UP TO 200 AMPS
FZ aseami Lic.# 1
eo< Dare Co true 3 201-IR00 AMPS
I '- tg 44tARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Oz-e Icode rstood my p[.,,h.11 he used as public records. OVER IWO AMP
F� W SIGNS ELSOICAL
4 Licensed Professional
Lid' OWNER-BUILDER DECLARATION SPECIAL CUTUMISC.
XO a F I hereby afflrn that I am exempt from the Contractor's License Law for the
W'3 W rn following reason.(Section 7031.5,Rosiness and Professions Code:Any city or county TEMP. ETER OR POLE INST.
which requires a permit to const a 1,alter,improve,demolish,or repair any suuaure
NTS priormits issuance,also requires the applicant forsuch permit file asigned statement POW RDEVICES
ns
W A p that he is liceed pursusnuo the provisions of the Contractors License Law(Chapter
M p,oC' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) 5 IMMINGPOOLB 1C VALUATION
XW
to or fiat he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS -PIXY S
dSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
On more than five hundred dollars($500).
nW' w n❑ I.asawneroftheproperty,ormyemployecswithwagwastheirsoleemmpensatiom, NEW RESIDENT L STORIES TYPE CONSTRDCTION
p, will do the wmk.andde,,dt arm is not imendedmmffercdtbrsale(Sce.7044,Business
and Professions Cafe:The Contractor's License Law does not apply w an owner Ile
propenywhobuildsorimpmves6ereon,andwhodoessuchwmk Nmselforlhmug his own
employees,provided thatsuch improvements arcual amendedoroffned mrsele. f, OCC GROUP RES.UNITS
however,the Bourgogne improvement is sold withinomeyearofcomplelion,the owne TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale J.
❑ I,as ownerofthepropeny,am exclusively contracting with licensed contractors to Q PL TNG PERMIT FEE FLOOD ZONE AEN,
antrum the project(Sec.7144,Business and Professions CMc:)The Contractor's P IT ISSUANCE
License Law aces not applyto an ownerofpropeny whobuildsorimpowesthemonand
who contracts forsuch projects with acontractons)licensed pursuant to the Commeror's ALTER- IN&VENT-WA R(FA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK PLOW PR CT.DIVICH OUTSIDEF899
SANITARY Y N
Owner Date RECEIPT#
COND
AREA,, .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL TAX YN
❑ Ihereby affirm thatlhave acertifcere of cnnsem mself-insure.oracenificere of RECEIPT is
XTURES-PER TRAP ��
Workers'CompensmN
itnsurance or accni0ed copy thereof(See.3900,Lou CJ which PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Cenificd copy is filed with the city inspection divieiov. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for mnehundreddollarspHOO) SEWER-SANITARY-STORM EA.20OPf. ENERGY FEE
or less.)
I oddity that a onion flhe work forwhich this permi[is iasued,Ishall RH ER W/VENT/FLECR
n 11 employ son w an t anter so as to be pre pphlect a Workers' PAID -
COmpensati foto' . a [[BB WATERSY EREA'PING pate Receipt#
ppTIlicanr
NOCET APPLICAN ,aft
T:Irtt�this Certificate of Exemption,you should RESIDENTIAL PLMB. SQ.FT. TOTAL: -
bea0 a subject o the Worker's Cnm sation provisions of the Labor Code,you must
forthwith comply with such provisin onhis permit shell be deemed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
mi
()
the work for which this t is issued(Sec!3097,Co.C.) ELECTRIC FEE p p
i Q FLender's Name
Lender's Address QTY. MECHANICAL PERMIT FHB PLUMBING FEE
k; cone I certify that I have read this application and state that the above ofmrs-a.is MECHANICAL PEE
correct.I agree m comply with all city and county ordinances and store laws relating to PERMIT ISSUANCE
LI) building construction,and hereby aufimize representatives ofthis city in enterupon the CONSTRUCTION TAX
L) "� above-mentioned pidy
Kifyri!nd
"on pury0 ALTER OR ADD TO MECH.
(We)agree to kc armlss the City of Cupertino againstliabilitie,jutlgme se ch mayin way same against said City AIR HANDLING UNIT(TO I O,000 CFM)iacomsequcnc it
AIR HANDLING UNIT(OVER ILODO CFM)
ignat o[ ppmam/Commd. Dare EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MA DISCLOSURE
HEATING UNIT(TO IOQ600 BTU) Date Receipt#
Will thyme Cupnt or ertino omitre ipdingoc,Cant pter9.2,hait le the I Edda
smatfety HEATING UNIT(OVER I OLOW BTU)
as defined by the Cupertino Municipei Coda Chapter 9.@,end the I leelth and Safety
Code,Section 25532(a)7 VENTILATION PAN(SINGLE RBSID)
❑Yes ❑No
BOILER-COMP LINE OR 100,000 BTII) I,ySSU�N�E�ATE
Will theapplicenlor futurebuildingacoupent useeyuipmem ordevicee whichemit fir+
hazardous air cmnmminants as defined by the Bay Arca Air Quality Management BOILER-COME(OVER 100,000 BTU)
District?
GOT 28. 1994
11 Yes 11 No NEW RESIDENTIAL MECH. SQ.PT.
1 have read the hezwdons materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533 and 25534.I understand that CITY urliurClyp 1f �
if the building does not currently have a tenant,that it is my responsibility to notify the l�,'YY7
occupant of the requimnents which must he met prior to issuance of a Certificate of �..�/� �r
Occupancy. V c ' t�l
Owner or nmhorized agent Date TOTAL: ISSUED BY:
OFFICE