27740 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Ifni l..I,,11-- 11' rR GA' PERMff NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /� �1J /N4O
6UII,DO
INPROJECI'IDN,N'1'IFICLATION
'I.DING ADDRESS: L SANITARY NO. APILICA'HONSUBMI'ITALDAM
OO (/i `LL UNITN LOT#
NER S A. PHONE: CONLIC NO: NIC { CONTRULN 111
7 CHuRcN
IIIIECT/EN INEIiR: LIC NO: ADDRESS:
ICONkCT: PHONE: BUILDING PERMIT INFO
Q G N ll k.G �, QTY. ELECTRIC PERMIT FEE
,ItLDV, EL[CI' M 1
PERMIT ISSUANCE I�I I(d`
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL.
OCA I hereby affirm that l am licensed under provisionsof0apier9(commencing with JOB DESCRIPTION
�00 Section 7000)of Division 3ofthe Nusinessand Professions Code,and my license is in PANELS
C m t full force and effect.
< Lactate Class Lic.a UP TO 200 AMPS �'
ti Q S Dam Cuntmcmr 201-1000 AMPS
.^ SQ.FT.FLOOR ARIL. S/SQ.Il'.
%Or'z ARCHITECTS DECLARATION OVER IOW AMPS
O%—O I understand my plane shall be used as,public records. N�O
SIGNS ELECTRICAL <
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCULT/MISC. T'__
X I hereby atrnn that 1 nm exempt from the Contractor's License Law far the
511
cl3: ~iI following reams(Scnion 7WL5,Dusincss and Pmfessions C :Anycityurc...1, TEMP.MEIER OR POLE INST.
which requires a Pcnnh to construct,alma improve.dcmolia o pair any structure
ifile i,saloommenl POWER DEVICES
ctor'sLicem Law(ChiperSWIMMING POOh F,LIiCIRIC9(commencing with Section 7000)ofDivision 3 ofth usmessand esvmnsCode) VALUATION
=y onhm M1e is cxcmpuhcmfrom and the hasis for the agedexemption.AiolationofO t%Q Section 7031.5 byaay aplicant for apennims r,offienpplicantmuc it penahy of UTI.FTS-SWITCHES-Fl%TURE
r more than rive hundred dollars(5500) #
WL- NEW RESIDENTIAL F.LECIR SQ.FT, STORIES TYPF;CONSTRUCTION
�F22 ❑ i,the wok andthe sspeny,ormy )loyees with wages astheirxnlec npensmiom
13— will do the work.sndrheaWcture' rut in tendedororcerodforsalets«.7 ,Business
and Professions Corr:The tmetors LiocmO Law does not appy mr of
pmpenywhobuildsori )vesmerenn.andwhodoessuchwnrkhimselfort o ughhis
employees,pr ed that such impmvementenne not imendedorofferol sale if. tJCC.GROUP NES.UNITS
however.d ing otim,rusimm,is sold within one yew ofcompution.th o 1
midw avill ve the huMcn i f Moving that did build a improve for p w of
sale.).
❑ Lansaw -rofmcpmpe c ngwimlice contractomm QTY. PLUMBING PERMITFEE I1.00D LONE APN
mstmm 'er the inject ISS5c.7 ofessiwas C . The Curnrac,m's
Lites Lawd saotapply.l propcny who buil improves thrOwn.md I PERMIT ISSUANCE,
whocontmmsf suchprojcc <ommnogs)lianu 0o the,Contractors
License law. ALTER-DRAIN&VENT-WATER(EA) FEC SUMMARY
❑ I am exempt underlies. .B&P C for this reawn BACK FLOW PROTECT.DEVICE OUT:UE IgeES
SANITARY Y N
Owen Dam DRAINS-FLOOR.ROOF.AREA,COND. RECEIPT N
W( KMANCOMPENS ONDECLARATION SCHOOLTAX Y N
❑ Ihembyaffitmt mlhaveacenifir.J fconunno selLinsurc,ora ccnifcmc of XTURES-P' 'f P �� RECEIPI'p
Wnrken'Compensmio Insurance nram�itifed copy thereof(Sa.3g00,Lab CJ which PARK FEE Y N
RE fp
crsullempluyeex. crda,pc GAS-FA.SY C.40UTLETS 6U11, rU ISION PIiES
Policy N
Company GAS.EA.S S -OV' EA) PfANCHECK FE
❑ Certified copy is hem f miehed.
[:1Cenificd copy is fled wnh the city inspection division. GREASFnNDUSTRL WASTE] "OR GRADING
CERTIFICATE OF EXEMPTION MOM WORKERS' GRP.ASETRAP V SOILS FW
COMPENSATION INSURANCE a
(This victims need not be completed if Ore permit is Intone hundred dollars(S100) SEWER-SANITARY-S N 2YIT ENERGY
or lexsJ
I cenifythat in the performance of the wink for which this permit is issued,lshali WATER HEATER W)VENTIELEC
not employ any person in any manner so as to become subject to the Workers' PAID D
Compensationlawsnf Culiforna. Date WA'TF:R$YSTEM/1'RIATING Date a ipl
O z Applicant
z NOTICE TO APPLICAMI':If.after mekingmis Cenilicateof Exemption,y.a,h..Id NEW RESIDENTIALPLMB. SQ.PI'. TAI.;
become subject to the Worker's Compensation provisions of the Labor Cale,you must
forthwith comply wish such provisions or this permit shill be deemed revoked. BUILDING FEE JIL
0. Q CONSTRUCDON LENDING AGENCY SEISMIC FEE
1 hereby affirm that hem is a construction]ending agency for the performance of
U O the work for which this penult is issued(Sec.3097,Civ.C.) ELECTRIC FCC
lender's Name D" PLUMBING FEE
E•' lender's Address QTY. MECHANICAL PERMIT FEE `
0 U I certify that 1 have tad this application and state that the above information is Mf:CH
T correct.l agree m comply with all city and county Ordinances and st laws relati.% PERMIT ISSUANCE
rL" building consiructinn, Jhereny u.,harrsc Jim. tivesof disc orrawripun re ONSTRUCfION TAX
V z about-mcmioned pm sty fur inspection pu ALT'ER OR ADD TO MEC]I. O
(Wc)agree t ,indemnify and k p has less the Ci upeo ci against
Iiabilities,judgm so Is. aspens Ich ayinuny w' a againstsal ICiy AIR HANDLING UNIT(TO 10,000 CFM)
in co the gr go c �a
( AIR HANDLING UNIT(OVER 10,00(1 CIM) 4 14—F
p nrlCumnmq Dam EXHAUST HOOD(W/DUCT) PAI
IIA' RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,gX)BTU) � Date Reccipt#
Will the applicant or future building occupant store or handle haeardovs material t1EATING UNIT(OVER 100.1100 B'I'U) TAE:
us defined by the Cupertino Municipal Code,Chapter 9.12,strips,Health and Safety
Code,Section 25532(a):' VENTILATION FAN(SINGLE RISID)
❑Yes ❑No ISSUANCE DATE
Will dacit,iverm a fmurcbuildingoecupanmmequipaenm ordeviceswhicb emit BOILER-COMP(3HPOR IW."BTU) L4
mssandem air contaminants a;defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,010 HTU)
Ssmet7 RESIDENTIAL Oct 91995
% ❑Yes ❑No NERESIDENTIALMECH. SQ.FT.
1 have mad the hasstdous mmedals"Itaimmcros wader Chapter 695 of the CII Y Ur
California Ileaah&Safety Code,Sections 255115.25533 and 25534. 1 understand that l#UrtH I ta,,)
if the building docs not currently have a tenant.that it is my responsibility to nitrify the
cupant of than requirements which must be,met prior to issuance of a Certificate of
Occupancy.
Ownem,volionacd agent Dole T ' ISSUEDBY:
ZOF
OFFICE