27581 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO FI¢D]NG-FLE,MICA• PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING P Rtt ECT[I)IIAN1FIC 27581
BUILDING PROJECT IUEN'1'IFICA'1'IO:V
BUILDING ADDRESS: / //_{� SANITARY NO. APPLICATIONSUBMOT'ALIMEE,
!11 0-5 .s6 e Q�u (: J NIT, LOT, ��1
OWNER AME.: PHONE: CON'IRACIOR'S NAME: hIC NO:
p �y �5.. N/C CONTROL#
OrH F,Cf/FNGINEER: LIC NO: ADDRESS: ❑
ON'IACI': PHONE:
QTY. ELECTRIC PERMIT ELF, BUILDING PERMIT INFO
BLDG ELECT LU 1B MF,CH
PERMITISSUANCE El
rDale
ICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nwz affiml that l am licenwd underpruvisioreof Chapmi)o,crmencingwilh JOB DESCRIPTION
woo of Division 3 of the Business and Professions Cede,and my license is in PANELS
y T-. effect.
TQ.LWs Lie.# UP TO 200 AMPS .
rn?yContractor 201.1000 AMPS SQ.FT.FLOOR AREA 8/SQ.FC
ZOvNizARCHITECTS DECLARATION OVER 1000 AMPS
OZ_- ond my plans shill he used as public records.
F,,11F al I SIGNS ELECTRICAL
Q EJ Licensed Professional
L,xQ OWNER-RUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyU I hereby of irm that 1 am exempt from the Contractor's License law for the
w3wHQ following rcawa(Section 7031.5,Busincxswld Promoions Cede:An t t TEMP.METER OR POLE INST.
,L:0
which requires a Permit to construct,alter,ire y ci Y r3 coon y
pe prove,demolish,or repair any wnure
d,WY2 prior to its issuance.also ownires the applicant her such Permit to file a signed statement POWER DEVICES
pt.(Y<O that he is licensed pursuant to the provisions of the Contractors License law(Chapter SWIMMING POOL ELECTRIC
ado 9(commencing with Section?")of Division 3ofthe Business and Professions Code) VALUATION
W^on or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
FZa
Section 7031.5 byaoyaoplicamfor.pe.itsubjcc.theapplicanno a civil penalty of OUTLETS-SWITCHES-FIXTURES
�y0 not more than rive hundred dollars($50Y, NEW RFSIDENTIALELECURSQ.FT.
C p ❑ I,asownernfthepmp ay.ormyemploymswithwagu iheirsolecompcnsauon. STORIES TYPE CONSTRUCTION
bo
3°_ will clothe work,and the structure isnm intended oroRered forsale(Sm.]M4,Business
and Professions Code:The Contractors License law does not apply to an owner of
,.,ladywh,,buildsorbnprovcs there..,and whodoessuch work hireselronho wgh his
on employas,,novided that such improvementsam not lmendWoroffered forsole.If, OCC.GROUP RES.UNITS
however,the huildingor inns nvemcm i+sold within one year of completion,the owner- 'TOTAL:
builder will have the burden of proving that he did tot build or improve for purpose of
sale.).
❑ I,avownerofthepropeny.amenclusivelyconl tingwimlicervedwnwcmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
omwn the project Sm.7IN4,Business and Rofeaxians CWe:)The Convenor's
License lawdoes not applyto anownerofpro,edy whobuildsorimpAo,cxderten,and PERMIT ISSUANCE .00
who comma for such projects with aconvacorts)licensed porcunouo the Contractor's ,LIFER-0 (EA)Limexe Law. ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Ellis mason OUTSID;FETES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dem DRAINS-F100RROOFAREA, RECEIP 4
, , , .
WORKMAN COMP17NSATION DECLARATION SCHOOL TAX Y N
❑ IherebyaW=ffiatlhaveacenificamofconsentoself-insum,oraudificamof TEXTURES-PER TRAP RECEIPT,
Worker,Compensation Insurance or a carried copy thosif(Sea 3800,Lab C.)which PARK FEE Y N
rs all employee a under NM
is permit. GAS-EA.SYSTE -I INC.4 OUTLETS RECIi1PT M
coven
# BUILDING DIVISION RIES
Grmp:my GAS-EA.SYSTEMAVER 4(EA) PLANCHECK REE
❑ Cer ified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division. OR EB STRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE 01:EXEMPTION FROM WORKERS' GR SETRAP SOILS FEE
COMPIENSATION INSURANCE
(]Tis section need notbc camplemd ifthe permit is Ichor hundred dollars(510(y 5 ER-SANITARY- RM EA.200IT. to
ENERGY FF.E
or less.)
I certify IM1at in the pefimninee.f the work on which this,omit is issued.I shall ATER HEATER W/VF,NT/EL
not employ any person in any manner m to o become subject m Ne Wmkers' I-AID
Compensation Lawsof California. Dam WATER SYSTF,M/IREATING Dam Receipt#
OZ ApplNOTICm 'W RESIDENTIALFLMB. SQ.IT. TOTAL:
z n Ncome suOAPo The Worker's ompensing Nis Ceruses of fExemption,you should
F y become comply
it Worker's visions r ionpmvisionaofthe labor Cs.ked.umoa
� > foMwio comply with such provisionsmthis permit shill be deemed rcvokrd. BUILDING FEC
[� CONSTRUCDON LENDING AGENCY SEISMIC FEE
z Ihereby affirm that is a commotion lending agency for the pswoomor",m TO'fAl.: ELECTRIC FEE
U O the work for which this permit is issaW(Sec.3097,Civ.C.)
I<nder's Name PLUMBING REE
4' F Leader's Address QTY. MECHANI ALPERMIT FEE .00
O V 1 moil,tom 1 have mud this application and state thil the above inmmardio is
>" f11 correct.I agree to comply with all city and county ordinances and state laws relafin to P ISSUANCE MEEHAN ICAL FEE
M1uildingamawniun,add hereby euthnriu repreaenutivesmfthis city to emerupmi
V] CONSTRUCTION TAX
U Z aMwementionnl property for inspection purposes. ALTER OR ADD TO MECH.
(Wc)igrcc m nave,imlemnify and kap harMexa Ne City of Cupc inn s inst
liuhilities,jndgme aind ex,whxwwhich may newly way se< agar twt City AIR HANDLING UNIT(T'010.00)CFM)
n cons�quen thc,awing riparian DLING UNIT(OVER 10.000 CFM)
r of AppllcatNCmnraetm am E THOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOgOW BTU) Date Recent.#
Will the applicant car furore building occuWm store or handle Tornadoes material IOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100,000 BTU)
Cede,Section 25532mE VENTILATION FAN(SINGLE RESTD)
❑Yes ❑No
ISSUANCE DATE
Will theapplicam crfatme building«cupanmicescipereed ordevices which emit BOILER-COME(THE OR 10(i BTU) PAID
� P1
hanirdims air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 RTU)
Discreet?
❑Yes ❑No NEW RESIDENTIAL.MECH.-SQ.FT. 311995
01 have read the wooden marorials re,niremems under Chapter 6.95 of the 'JA•_ 1 •#
California health&Safety Code.Sections 25505,25533 and 25534. 1 understand that �/
Elbe building docs am currently haven tenant.that it is my responsibility to nnlifythe lalTM OF �UI'
(account of the requirements which must be met prim o issuance of a Ceniftcam of '
Occupancy. FT
Owner m nuthnme#d.sero Date 'ICTAL: ISSUED BY:
OFFICE