27805 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UIGmNG—FTECTC I PERMIT C
APPLICATION/PERMIT rLUMRwG-mEcunrvlcnl, n 7 p O C
/'o BUILDING DIVISION INILUING PRf3JRC1'IDRY'fIFICA'1'ION L / OO J
0 BUILDING ADDRISS: a SANITARY NO. APPLICAT1IO�NSU
BM
I-TALDA)E
loO LOT
WNERS ME:O %a ,VG i4zZ-1 zC 7 Mia ws NN/C CONfROLX
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C1HMC7r/ENGINF.ER���� LIC NO: ADD 5: D�, Gr✓/r r / �� �a r ❑
ONI'ACT: PHONE: L/G��L
QTY. ELECTRIC PERMIT FEE BUILDING PER INFO
BLDG f PLUMB MECH
PERMIT ISSUANCE r ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIVI'ION
Ver Z I hembyaffinn that l am licensed order p-oisi^nsafCbapmr9(enmmc^cin,with � �
[�+lOC Section 700(oor'Dlvision Sol'the Business and Prefeowns Code.and my license is in PANELS
Wd,ZEmu farce,rrta'Beet. ^
Liccns Cl Lic.n�36f/9/ UP TO 200 AMPS r
m G d Dam Contractor 201-1000 AMPS
Fy2 ARCIIITECTS DECLARATION SQ,FT.FLOOR AREA S/SQ.FT.
0z`=E 1 undcn andmy plans shell be used as public recods. OVER 1000AMPB
PSIGNS ELECTRICAL
Y licensed Prof ssionsl
C WQ OWNER-BUILDER DECLARATION SPECIAL CIRCIIIT/MISC.
XOatJ I hereby affirm that I em esern,from dim Contractor.Littre¢law for the
W 3 tL y following resson.(Station 7031.5,Business and Professions Code:Any city memory. TEMP.METER OR POLE INST.
F sx Oo.J which requires a permit to construct,alter,improve,demolish,m repair any structure
�.Y2 prior its issuance,alsomquirss the applicant for such penrduo file a signed statement POWER DEVICES
0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
p'Ke� 9(commencing with Section 7")of Divismn3ofNe Business and Professions Cade) V_ ALUATION
ty_y or he is exempttherefrom and the basis far the alleged exemption.Any violation of �'
I—ZQ Section 7031.5 byinyapplicant fora wount,objects the appli<anuoecivil penalty of OUTLET'S-SWITCHES-FlXTURES
�St] nm marc than fivchundreJ toll., NEW RFSIDENTIALELECIR _S(.FT.
CFo ElLasawncroHhcptoper .ormyemployceswilh agesastheirsolecomitensood, STORIES TYPF.CONSTRUCI'ION
y3o= will doda,work.andthesir lire is not indndedoroffe d for sale(Sec.70.14.Business
and Pndr,sions Cede: CnnnacoWs License Law our apply to an owner of
in arly whohudd.,mi p,ovw hr,rm, ,d wh.t au wnrkhintwifor,hom,dihin
own
cmployces.prov edthatauclrimprovenentsamnnin ded^rofferodl'nraale.IL OCC GROUT' RES.UNITS
however,We hail] orimprmvement is sold within eros year fntmplerion,theowner-
huildef will h.v c bunlcn of proving that he did nm build n improve fur purtsi.i f
role.). QTY. PLUMBING PERMIT FEE Fl.GGD'rorvr APN
❑ Las erafthepmpcny,um usicv wineCod sedcCommonm
'oceans hepr)ject pplytio, o ner c o h.1Sessions or inns fie Contractor's
wherein tsfors ch,imyroa owner pe(s)[in ' impmvesthcreoo,ond PERMIT ISSUANCE
wbocontts forsuch pmlccts ith rorts)1ic pursuanuo the Contncmrs
Licenu Lm. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am a rept and- S .B&P C for Nis reason SI
BACK FLOW PROTECT.DEVICE UI: GS
SANITARY Y N
Owner Date BECEIPTX
DRAINS-FLOOR,ROOF,AREA.COND.
WO,h. NCOMPEIJSATIONDECmifins ON SCHOOL TAX Y N
I h'Com mmon ti mnWoriicendie consentrsid(er.38o,sat,C.) hickteof FIXTURES-PER TRAP RF,CEIPTp
orken'Com nsotionI urana�or acenificd copy thereof(Sec.J800,Lab CJ which PARK FEE Y N
n all emph sex under tht's permit. GAS-EA.SYSTEM-I INC.4 OUTLBTS RECEIPu p
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 EA) PLANCHECK FEE
❑ Ceniliedm yi Imrebyfamishvsl.
❑ Ceririedmt s filed with the city inspection division. GREASFIINDUSTRL WASTE INrERCEP1'OR GRADING FEE
CHR'I IFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section ncctl not be completed ifthe permit is rorone hundred dollars IS l00) SEWER-SANITARY-SI ORM ITA,2001°I'. ENERGY FEE
mlii'a)
I cmtify that in the perforinsucenf Ne work for which this permit is issued,I shall WATER HEATER W/VENT/LLECIR
not employ any person in any m a'to become subject to the Workers' PAID
z Cmmpcnsation Lawsof Glifomis. Dare so WATER SYSTEM/TREATING Dare ReccildN
Applicant
z NOTICHTO APPLICANT:IL surer making this Certi Es lion.yyyyou NEW RESIDENTIAL PLMIL SQ.PT. TOTAL:
to becom<subjcctmthe Workers Compensation provuio o t °sf•must
forthwith comply with...hprovision. drispe hal m�',yuN1I C�vok BUILDING IFF.
LV V SEISMIC FEE /r
0. Q CONSIRU(TIQ L 1 1 AGF
1 hereby affirm that there is a c�a on IcrMin ncy r rhe per ersaii of
U U the work rod which this Mai ssud( 3097,Civ. TOTAL: ELECTRIC FEB
perm
Lender's Nome
OF Lcndcrs AOdms, QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
U 1 orm y thin 1 have read this application and stem that the above information is MECHANICAL FEE
correct. I agree m comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE
f— p" building consvucrion,.nd heathy smhnri,c repremounivesofthis city to cntcrurysn the
nMwemm�tioncd n tori^.' tion ALTER OR ADD TO MSCI{, CONSTRUCq'ION'fA%
V pngx Y pec purpose
(Wc).g,c indemnify and I the City of Cupertino against
Iiubilities,jud c las and expenses w nary Cupertino
said City AIR HANDLING UNIT(TO 12111X)Cl
an um,eyue s gmdmit0 thispe n
AIR HANDLING UNIT(OVER 10."CFM)
Sila ApplicanVCoi mcmr Dare EXHAUST HOOD(W/DUCT) PAID
I IALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date rip,It
illilrcapplican0 or futunbuildingaccupamsmmorha Icha dousmatcdal HEATING UNIT(OVER 100.(X10 BTU)
ss de recd by rhe Cupertino Municipal Code,Chapter 9.12.and the Health and Safety TOTAL:
Code,Sce.m.25532(.)? VENTILATION FAN(SINGLE fil
❑Yes ❑No
°ISS NCP•bATE
Will the opplicamor future buildingcecup tuwequipmenrurdeviceswhichemit BOILER-COME OHP OR 100,000 BTU)
endows air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER IW.0(X1 BTU) I�pR 15 1995
iatrict?
❑Yes ❑No NEW RESIDENTIAL MECI{. SQ.FT.
1 have read the haxardna,materials regairemems made,Chapter 6.95 of the CI I Y UY LILIPEH I INO
Calirmnia Health&Safety Code.Sections 25505,25533 and 25574. 1 understand that
If the building dues not currently have a tenant,that it is my responsibility to ramify the
ectp,ant at the rnyuircmmmm which must be met prior to issuance of r Certificate of
Oo.c'my.
Owner or uuthnrimA agent Date TOTAL: ISSUED BY: