27980 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRIAL PERMITNO. /� (]S O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION LJ
BUILDING ADDRESS: - SANITARY NO. APPLICATIONSUBMITTALDATE
O 420 �IA103el AVe. UNIT» LOT#
OWNERS NAME[ PHONE: CONTRACTOR'S NAME: - LIC NO:
MR. -4-Acge om"-I.v. laJON 4F4Qr A4UAV4w G20$4Z wG CONTROL#
FARCHITECOENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
�Q✓�N• .Z SS•t3iSS, PERMITISSUANCE e
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL /�_ r CRIPfION
OCZ
thereby efOrLICENSE licensed uACTORvisDECL DECLARATION
TJ '[`l`
�r100C
Section]WG)of Division 3.fthe Business and Professions Code,and my license is in PANELS
VU fm]force dna amen.
E¢- [�2License Class G �6 Lic.# G2014 UP TO 200 AMPS
m 5 h Date Contractor 201-1000 AMPS
AR 1'TF:CTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Z O m OVER IOW AMPS
po 1 understand my plans shall be used az pmblic records.
stn W SIGNS ELECTRICAL
Licensed Professional
�C
F U OWNER-BUILDER DECLARATION SPECIAL CIRCUILMISC.
g3 1 hereby affirm that 1 am exempt from the Contractor's License Law far the
p� Om following reason.(Section]031.5,Business and Professions Code:Any ch......aty TEMP.METER OR POLE INST.
m.Q] which requires a permit to construct,alter,improve,demolish,or repair any structure
5 a
pit.mmus...ovule,�lsoregmresthe applicant for such pe mint file#lig ed statement POWER DEVICES
WW O C) that he is licensed pursuant m the provisions of the Characters License Law(Chapter
a X�li 9(commencing with Section]000)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W," , or he is exempt therefrom and the basis for the alleged exemption.Any violation of
[-. ¢ Semion]031.5 by any applican[for epermiaubjects the applicant[oacivil penalty of OUTLETS-SWITCHES-FlXTURES
,y^S not more than five hundred dollars($500).
❑ I,asowneroftheproNny,ormyemployeeswithwagesastheirsel¢compensation, NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
d3-- will do the work,and Iestructure is not lacendedoroffered forsale(Sec.70PL Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or i mproves thereon,and who does such work himsel f or through h ie
own employees,providedthntsuchimprovements meaa.imendedorofferedforsale.It,
OCC GROUP RES.UNITS
however,the building or improvement issold withinone year ofcompletion,drommel. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owncroftheparperty,amexclusively contracting with licensedcontmctursto QTY. PLUMBING PERMIT FEE FLOODZONE APN
nnsruct the project(Sec.7044,Business and Professions Code:)The Contra ma
LiceecLawdoes not apply to an ownerofproperty who builds or improvesthereon,and PERMIT ISSUANCE
whocontractsfn-such projects with acommorons)licensed pursuantmthe C.nnacmr's ALTER FEE SUMMARY
License Law. (EA)
❑ 1 am exempt under Sx. ,B&P C for this meson BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y-N
-
Date Dace pRA1N5-FLOORROOF, COND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihemby.M.that l have a certificate ofeonsenno self-insure,or a certificate of RECEIPT#
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE YN
cavees all employee's under this Permit. GAS-EA.SYST ENTI INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATEOFEXEMNFROM WORKERS' GREASE TRAP SOILS FEE
COMM S�TIO URANCE
(This section need not be cored op ep it is for one hundred dollars($100) SEWER-SANITARY-STORM EA.2001T. ENERGY ME
or 1.x.) /)
I certify thI the if nc ¢work for which p/�pp issued,Ishii] WATER HEATER W/VENT/ELECfR
not employ any iso n aper so as becmnNeup� [o the Workers PAID
z Com cnsmio La of if h, Date I is WATER SYSTEM/I'REATING
F Dem Receipt#
y NOTICETOct NT:e.of r fi�nn[ sCertificatem Exemption,you should NEW RESIDENTIAL PLATE. SQ.FT. TOTAL:
Flt become subject m th� orkera C sp iSsdtion provisions of the Labor Cade,you must
� ; forhwi[hcomply wit..ouch provisions'or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm mat them is a construction lending agency for me perfartnpce of ELECTRIC FEE
C..) O the work far which this permit is issued(Sea,3037,Civ.C.)
Pp.y Lenders Name
Lenders Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have read this application and state that the above infwnatiun is
coram.I agree to comply y y or g MECHANICAI.FEE
g pywith all cit and count dinances end amts lewsrelatin m PERMIT ISSUANCE
N building construction,and hereby authmize representatives ofthis city to enter upon the CONSTRUCTION TAX
L) 'Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any waytrue an id City AIR HANDLING UNIT(TO 10,000 CFM)
in conseyuence of the granting of mil permiC _ !��
`v AIR HANDLING UNIT(OVER I0,000 CFM)
Signature of Applicent/Contmctor & are EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALSter DISCLOSURE
HEATING UNIT(TO Hal"BTU) Dam Receipt#
Will the the Cupertino
moMunicifuture pal Code,
Cantsmreor handle Heath and Safety
HEATING UNIT 100,000 ETC) TOTAL:
al
as defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Sefery )
Cade,Section 25532(a)?
ElYes CI No VENTILATION FAN(SINGLE RESID)
' ❑
Will theappliwn[orfvturcbuildingoccupenmuequipmen[ordevicee which emit BOILER-COMP(3HP OR 100.001)BTU) ISSUANCE DATE
azardous air contaminant.es defined by the Bay Area At,Quality Management BOILER-COMP(OVER Hill,"BTU) B
fdwio? ter, p
❑Yes 0N NEW RESIDENTIAL MECH. SQ.FT, n+' Y�
I have read the M1azaMous materials requirements under Chapter 6.95 of the
Culifomia Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that �✓ Y
if the building does not currently have a tenant,that it is my responsibility to nmify the
occupant of the requirements which must he met prion to issuance of a Certificate of �
Occupancy. �0
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE