27945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPF.RTINO Dff:611VC-F. � PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECIUNIPICA 27 A /I C
RUILUING I'ROJRCI'IUENTIFICA'I'ION J f•�J
HUILDINGADDRESS: SANITARY NO. APPI-ICATIONSUBMI TALDATE
O e ��Clj�'� �rt eti swi
OWNERS NA T�7 �-. COt�iiR /�/I /��LIC N/C .CONI
ARCI IITELT/ GINEI'R: LIC NO; IIgo& LlJ/1//7r �S s� l .•�da ❑
CONTACT: PHONL•: H BUILDING PERMIT INFO Y. ELECTRIC PERMIT 'FI:E
ufj J�l 1 BLDG ELECT UMB MF.CH
PERMIT ISSUANCE /IyK�yJ� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Cl9z I hereby affirm that l am licensed underprovisiomofampter9(commencingwith TOB DESCRIPTION
Ps 00 Section 700P of Division 3 of the Business and Professions Code,and my license is in PANELS
K full force and effect. �f�/
FZ� License Cles Lic.p�� IIP T0200AMPS an y �/ `_^ O
H 6 y Dale Contractor
A577,
201-1000 AMPS F—C�VY
ZOtV'itZ ARCHITECTS T OVER IOOOAMPS SQ.PT.FLOOR AREA S/gQ.FT.
O Z—E I understand my plans shall be used as public records.
F y C SIGNS ELECTRICAL
q Licensed Professional
L a'GGG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
.�Cyu 1 hereby affirm that I am exempt from the Contractor's License Law for the
Izl34m mHowingreasom(Section 7031.5.Business and hofessi.ns Cnde:Anycityoreaunty TEMP.METER OR POLE INST.
which requires a permit to r.mare taller.improve,demolish,morpau anymmatere
>�
POWER DEVICES
priorloilsissumce,alsomquimsihenM[icantforsuchpennillofileesignedsmi,mmt
GC) lhm he is licensedpursuant m the pmvieions of the Commnors Licenu Law(Chapter
L �' 9(commcncmg with Section]1X10)of Division3of the Business and Prafessiom Code) SWIMMMGPOOLELECMIC VALUATION
yYj'4_'y or that he is exempitherefrom and the basis for the alleged exemption.Any violation of as /I 0
(:^a Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTUM.SWITCHES-FIXTURES (f (f
F❑ not mom Than five hundrtd dollen(5500). NEW RIESIDENTIAL ELECI'R 5 .FT.
C� ❑ I,asownernllhepmpony,ormyemployeeswithwUcsestheirsolemmNnsation, Q STORIES TYPECONSTRUCTION
p, will do the work,and thestru tureis not meendedmofl'ered forsale(Sec.](F4,Business
and Professions Cade:The Contractors License Law does not apply to au owner of
property whobuilds orimproves themon,and who does such work himm1forthroughhis OCC GROUP RES.UNITS
own employeewpoevided that xuch improvements me not amended oroffered fmsale.If,
however.the buddingor improvement is sold within one yearofemopletion,Neowner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
..Jr.).
❑ 1,as
wneroOhe , sontmnh e:) sm
QTY. PLUM 0PGRIVTT FEE FL DZONE AN
oslrvnte project(S..7014,Business and Profesimeng ,CarThe ContractmA
PERMIT ISS CE 2 a
Lacerum Lawdoesnotapplytoanownerofproperty lihosedIdaca improvethereon,end
wbense Laws fursuchprojebts with econtmcmr(a)licens<d punuentmthe Contractors A _DRAIN&VENT-WATER(EA) FEE SUMMARY
License Low.
❑ml am exempt under ga. H&P C far This rewnn FrT—
HACK FLOW PROTI=DI!VICE SANITARY Y D N
Owner Data• R -FOR,ROOF,
RECEIFI'p
WORKMANCOMPENSATIONDECLAATION DRAINS RC .
SCHOOL.TAX Y
❑ Ihercby affirm lhatihaveacenificne of conxmtoselGinsure,orecertificatao RECF:IPI'p
Wnrker%Com FIXTURES-PER TRAP
pcyee'snler this Permit,
fled copythcrmf(Sieg JB00,LebCJwhich PARK FEE Y N
colics all employee's under this permit GAS-EA.SYSTEMd1N ETS REC
Policy p BUILDING DIVISION fT:FS
Company GAS-EA.SYSTEM
(KA) PLANCHF.CK PEE
❑ Certified copy is hereby furnished.
PlInnified copy is filed with the city inspection division. EASBpN S' WA41iB 1 C R GRADING THE
CERTIFICATE OF EXEMPTION MOM WORKERS' GRP A SOILS FUJI
COMPENSATION MSURANCH
(This sectionmeed not be completed ifthe permit is Forane hundred dollers(f100) SEWER- ITAR STORM EA.200FT. ENERGY PER
cur lase.)
I certify than in the performance of Ne work for which this permit is issued,l shall WATER HEA W/vENTR!LECTR
not employ any person in any manner so es to become subject to the Worker' PAID
Z Compensmionlswsof California. Date WATER SYS TING Date Receipt#
p O Applicant
y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PI. SQ.FT. TOTAL:
F h become subject to the Worker's Compensation provisions of the Labor Code,you must
I'onhwilh comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEI3
Uz I hereby affirm that there iso construction lending agency fm the pertomwce of TOTAL: ELECTRIC IEE
O the work for which thissh ponis issued(Sar.309],Civ.C.)
Lender's Name
O .. Isnders Address QTY. MECHANICAL PERMIT FEE PLUMBING PEE
1 certify thin I have read this city
and
and rete Net the above information is
1t building lagreemcamply with
yauthand wuntyordimnces and city[cIs.
nterupin the PERMIT ISSUANCE MECHANICAL FIiF.
U building consnedprgand herebypection authorize representatives ativee of this city[center upon CONSTRUCTION TAX
V uhnve(We)igrel propertyfor mnify and purposes. ALTER OR ADD TO MECII.
(We)agree m save,indemnify and kcep harmless the City of Cupertino againstIn"itiu,ju grvmi Is end �:pe which may innny way accrue against seat City AIR I IANDLING UNIT IT 010.fgq CFM)
in cans ce, r AIR HANDLING UNIT(OVER 10,000 CPM)
Sdodkp'f fiWimmucrontractidw Date EXHAUST HOOD(W/DUCTI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100.00)BTU) Date Receipt p
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Cada Chapter 9 12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: Z .o
Code,Section 25532(uyl
13 Yea ❑No VP.NTILATION FAN(SINGLE RESID)
100,01(s)BTU) ITT IS$UAN�DATE.
Will theepplicanlorfmurebuildingoccupent use cquipmenmrdeviccswmi
hichet BOILER-COMP(311P OR 100, Ir AA44 77
• heurdom air contaminants as defined by the Bay Ates Air Quality Management
BOILER COMP(OVER I00,g10 BTU)
Distrier?
❑Yes ❑No NT:W RESIDENTIAL.MECU. SQ.FT. APR 18 1995
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 2!5505,25533 and 25534. 1 undersand that Cil I Y'Ur iUYth I INV
i l'the building does rat cunemly have a mnutn,that it is my responsibility to notify the
cecupanl of the requirements which must he me prior 1m issuance of a Cm fleme of
Occupancy.
Owner or mthonu agent Dote TOTAL: ISSUED B � ✓�(i
O FI