27666 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO BUILDING-ELECT RICAL PERM]TNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n�I Ca
BUILDING DIVISION BUILDING PROIF,C'TIDESCIt'ICAI'ION G / v
BUILDING ADDRESS: SANITARY NO. APPLICATION SU//B��MITTAL DAIE
QFy.�rk yl Qr. UNII0 LOT#
GW`N
iRS NAM PHONE: CO TRAC'TOR'S N E: LIC NO:
4 voce �a� A-- 579 7 2 N/C C'ONTROi,p
HCIII'I I:C EENGINEER: LIC NO: ADDR S: I
El10V7q S. anz w, G-0.
CONTACT: PHONE: BUILDING PERMIT I NFO
�g 011 as,�_O�lp QTY. ELECTRIC PERMIT FEE
U+ 1 b�Js U BLDC ELECT U B MECII
PERMIT ISSUANCE El 1:1 ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RISIDINDAL
pCZ Ihcmby xffirm lhalam licensed underprovisioruofCM1apmr9(commencing with LOB DESCRIPTION i
V00 Section]0001 of Division Sof the Business and Parfessine,Coke,andmy license is in PANELS /�+f
,tve fulllbrceffect. UPT0200AMPS
d effect. � {—
E LiccnClass Lica I
ret Qd Dam ConOacmr 201-1000 AMPS
F yZ ARCHITECTS DECLARATION OVER UX0 AMPS SQ.FT.FLOOR AREA $/SQ.F'1'.
OO-0 l understand my plans shall be even as public records
F y!:; SIGNS IF:C'1
A, 'RICAL
QY$, Licensed Professional
C�9< OWNER-BUILDER DECLARATION SPECIAI,CIRCUUDMISC.
dO e.U I hereby affirm that I not exempt from the Contra is License law for
'3 a,� following resson.(Section]011.5.Business and Rufex a
re Code:Any city orriam TEMP.METER OR POLE INST.
F�-O; which requireso permit reconstruct,alter.improve emolinh.orrepowerystmetum
f'p�YF prior to its issuance,aleo natures the applicam ucb permit to file a signed statement POWER DEVICES
ty�j d',O than he is licensed pursumn It,tire provision the Convectors license Law(Chapter SWIMMING POOL ELECTRIC la.aoW 9(commencing with Section 7000)of - son J of the Business and Professions Code) VALUATION
tr- nrthat he is excor ttherefrn a basis thealle ed excerption.An olationof
Ixn'—^y P li cm�iun. yvi t
Fyr Semon]IIJIS ¢am(orepemrit subjects thea is noacivil pendtyofOUTLET
5H!<CI mu
SWITCHF,S-FlJCRJRES
< u on five hundred dollars($510).
N
wRESIDIiNT1AL ELELTR —SQ.FT.
yFm ❑ I, sowneroflM1CMopcnY,ormYemploYceswti as cirsolecompR inSTORMS 'IYPIi CONSTRUCTION
6'3— willdot work,and the stmcmmisnOt inlendedoro w4 (Sec.]U44,Busi
and Profs cions Cmle:The Cmmmctm's se s not apply I c
progeny wM1 buildsorimpm starters. n :such work himsglfor w h
employee ovidedlbat bi pr an ismenotiamnledu+yRe rat e.If. OCC.GROUP R13.UNITS
however,I1bebm ingorimprocis tld within one year 'a na,,hn.w TOTAL:
builder will have I horde ' g that he did not build or in for Po of
sale.). PLUMBING PERMIT FEE FLOOD ZONE: APN
❑ I,asowneraDhe mpery,. choivelycumAvividtlicen o contain QTY.
msunit the project(.-c. mess and qq\\oofessions Code: retention'sLicenvcl.awdmsnotnpp w,no r.Pospersy hobuildsor' proesslbere .and PERMIT ISSUANCE
who contracts for such pro ns with econve<mgs)licemed uantlolbe ConVazlor's ALTER-DRAIN&VENT-WATER LA
License Law. CEA) FEE SUMMARY
❑ 1 amesempt under Sce. .B&P C fur this mason BACK ROW PROTE;CI'.DEVICE TSIDI:FEES
SANITARY Y N
Owner Date RECEIPT#
URAINS-FLOOR.ROOF,AREA,COND.
WORKMAN MPEN, ION ..,CLARATION SCHOOL TAX Y N
❑ Ihereh ffirmthatlhave sec atcedurnmenuiselbimers.macertificamof RECEIPTa
Ya
s Workers'Compereation insurance or a certified copy thereof(3ec.3g00.lsb CJ whish FlXTURES-PER TRAP PARKHE Y N
rs all etnploycc's ands,this permit. GAS-EA.SYS TEM-I INC.4 OUTLETS RECEIPT is
Policy a BUILDING DIVISION FEES
Company GAS.EA.SYSTEM-OVER 4(G7 PLANCHF,CK FEE
❑ Certified copy is hereby famished.
❑ Cenifiul copy is filed with the city inspection division GREASMNDUSIRL WASTE.INTERCEPTOR GRADING FEE
CERI IIRCATii OF EXEMPTION FROM WORKERS' GREASE.TRAP SOULS FEIi
COMPENSATION INSURANCE
("I his section need not he completed ifthc permit ix forms hundred dollars P$100) SEWER-SANITARY-STORM EA.200F7. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this Permit is issued l shall WATI7R HEAT ER W(VENTAiLECTR
not employ any person in any manner so as to become subject Ise the Workers PAID
Compensation Lnwsof California. Date WATER SYSTEMORFATING Dam Receipla
O Z Applicant
Z � NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PENCE. SQ.FT. TOTAL:
E-' become subject to the Worker's Compcnsalios Provisions of the Labor Cede.you muss
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEC
tr..l QSEISMIC HE
6. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a e.murelion lending agency for the pcm
rtounce of
UZ TA ELECTRIC FEE
O the work for wbicM1 IM1ix permit is issued(See 3097,Civ.C)
Lender's Nan'c PLUMBING ME f
u'' F
Lender's nddmsa QTY. MECHANICAL PERMIT FEE
V 1 cenify that I have mad this application and sure That me above infortnotion is MECHANICAL.FEE
coned.l agree to comply with all city and county ordinances and state laws relating to PCRMITISSUANCF,
f•" buildingcomarr ioq and hereby outhoda rcprcsenutives of this city toemer upon the CONSTRUCTION TAX
U Z above-mcmimad property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,in�cx perton agaiml
Iiahililies,juJgmc P, .uwgainst said City AIR HANDLING UNIT(TOIO.g1UCPM)
iAIR HANDLING UNIT(OVER 10.001 CIT1)
Siga •nfAp team/Cont or J Dam`1 EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dam Receipt
Will the applicant or future building occupant store or handle herzrdous material TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heald and Safety ILEATING UNIT(OVER 100,(100 BTU) ggII��
Gale.Section 25532(m? VENTILATION FAN(SINGLE RFSID) V
C3 Yes ❑No
tlOILER-COMP(3HPOR 100,000 BTU) Puri
ATE
Will llneupplicanmr famrc building m:cupwmx cyui pmcm nrdcvices which emit
hteardous air emnioninwu as defined by the Bay Are,Air Quality Managenres. BOILER-COMP(OVER 100,000 BTU)
District El 4
❑Yes No NEW RESIDENTIAL MECII. SQ.FT. 90n[
I have read the foorch nus riancrials requiremm
es under Chapter 6.95 of the 'JJJ
if the wilding does
s Safety Coda avSectionsnam.that it is end 255Mresponsibility
I undcmand that CI1 Y ver t
if IM1ebuildingdoesnot curemlyich aseam.Lhao is myreepnnsibllitywnotify the
Ove..m of the requirements which mass be run poor,In issuance rf a Cenilicam of
aeaapnney.
Owner or au0orieed agent Dale TOTAL: ISSUED BY:
:1 C11W
OFFICE