27766 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B1UILVING-EI.ELF11 H,'AL PERMfr NO.
BUILDING DIVISION APPLICA(CFTI N/PERMIT PLUMBING-MECHANICAL
ILHNG ADDRESS: BM.DINGPROJEC1'IDENTIFICA'1'l(N G 76
.6
TARY NO,
APPLICATION SUBMITTALDA'D3
I r1 �1 UNITN LOT# 3i1�' ,s
I NIiRS NA :: PHONE: ��� CONTRACTOR'S NAME: -� LIC NO:
2 •V\ N/C CONTROL#
IHI'ECI'RAUNEEK: �, CI.()�� DD5: ❑
CONTACT: t PHONE: L•
0 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT'INFO
/ `
BLDG I:LFCT PLUMB :CII
/'• W LJ PERMIT ISSUANCE LaD /IM1A-s#`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RIiSIDEMfIAI' JOB DESCRIPTION
Cee? IherebyaffrnthailamlicensedunderpmvisionsofC apter9(commencingwith
ts100 fall dr]IXnd ofeDivisiont3of the Nosiness and Professions Cafe,and my license is in PANELS �
full force and effect.
<zlaOj
License Class Lia# UP T02lq AMPS
zy Dore Can201-lalfl AMPS SQ.PR FLOOR AREA E/SQ.FT.
TOoez ARCHARCHITECTSTS D17CLARATION OVER IOW AMPS
_ I understand my plans shall be cited as public records.
ytw SIGNS ELECTRICAL I�(/tac Iwo 3
Q-2j Licensed Professional <J V
S:,Xt OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
WL, I hereby aftimt data 1 am exempt from the Comracmr's License Law for the `
n3wFi following reason.(Section]031.5,Business and Professions Cade:Any city or county TEMP.MFT ER OR POLE INST.
(:�Q which msP u pc-,it 1.coreauq.item improve,demolish,or repair any structure
EWYS to its issuance,also the applicant such Permit rile a signedstatement POWER DEVICES
pnur quires pp poriLa
y C p p that he is licensed pursuant m00 provisiom of the votive
Busi m's License Lew(Chapter
myon� 9Qonnnencing with Section]0001 of Division3o[tbe Businesx and Pm[essinns Cale) SWIMMING POOL ELECTRIC VALUATION
W_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
�zQ Section'1031.5 by any applicant for a Permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FI ES S
KFonm morethan five hundred dollars($500). NEW RESIDENTIAL ELECTlz SQ.FF. ) 'TYPE CONSTRUCT ION
❑ LasowncrofthepmpenY,nrmyemPlnyeeswithwegeaas Neirsolecompensation, -
YB= will Jo lhework,and the structure is not intended oroffcred Preside
(Sec.90a4.Business
and Professions Code:The Contractor's License Law does not apply to ant owner of W
pe,onywhobuildsor improves duceon.and whodoessuch work himselforthrough his
wnemployees,lding or improvement
mem mpmv sold
wit arenot intendedondfered forsale.IL
OCC.GROUP RES.UNITS
builder ,sheave thegurdenodpmcntissoldwithinaneyear ofrorove for thrower- O
builder �I have the burden of proving that he did mol build m improve for purpose of
hasownerofthcpmpeny,amexclusivclyconvuningwilhliccnsecommctirsto QPY. PLUMBING PER FEE ILUOU-LONIi APN
oust t the project(Sec.]044,Business and Professions Code:)The Commnor's
License wJoesnsapply mon ownerofpropcny who buildsor improves thereon,and PERMIT ISSUANCE
who contracts forsuchprejectswith.emendector(s)licensed pursuanuothe Contractor's ALTER-DRAIN&VENT-WATER f
License Law. HJ
) FEE SUMMARY
❑ I aro exempt under Sec. .B&1'C for this.,,an BACK FLAW PROTECT.DEVICE. OUTSIDE I ME
SANITARY Y N
Owner Date RECEIP`F#
DRAINS-IT.00R,ROOF,AREA,CONU.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a certificaeofconcent loself-insure,orecanifcam of FIXTURES-PER TRAP RF #
kers'Comperes Pon Insurance or u cerci tied copy thereof(Sec.3800,Lab C.)which PARKME N
o
Mrs all employee s under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS 1. L
Poly# BUIL D 1 NFEES
Constantly GAS-GA.SYS'T'EM-OVER 4(EA) PLANCHECK FP'
❑ Ccnifeeopyi.shercbyfumished.
❑ CenilieJ copy is filed with the city inspection division. GREASE/INDUS'IRL WASTE INTERCEPTOR -3 GRADING FE49�i
ERTIIiCN'EOFEXF,MPOONFROMWORKERS' GREASETRAP SOILS FE COMPENSATION INSURANCE
(Thisscetionneednot lrecomplee ifthepennit isforonehundieddollars($10m) SEWER-SANI'T'ARY-S'I'ORM EA.2001'1. ENERGY MEor less.) I kill,
I certily that in the perfmmancc of the workfor which this permit is issued,I shall WATER HEATER W/VENT/ELF:CRnot employ any person in any manner so as to become subject to Ne Workers'mpenPAIDCosationf.mOmC.Iomia. Date WATER SYSTEM/TREATING Date z NOTT IETO APPLICANT:If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT.becomesubjectto the Workers Compensation provisions of the labor Cods,you mumforthwith comply wiN.such provisions orchis permit shell 6edeemed revoked. BUILDING FEE
cz
CONSTRUCTION LENDING AGENCYSEISMIC FEE
U z Ihereby affirm that there is a construction lending agency for the perfr anance of T ELECTRIC FEE
Q the work for which this permit is issued(See 3097,Civ,C.)
6 k-2-949
Lender's Name
D" F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
U 1 certify that 1 have rood this application and state that the above infarnmion Ps MECHANICAL FEE
rid
14.1 correct.I agree to comply with all city Paid county ordinances and state laws relating to PERMIT ISSUANCE
I--' building construction,and head,authorize represenutivesufthis city to enter upon the CONSTRUCTION TAX
U z abuse-mentioned p,,,,ny far inspection purposes. ALTERORADDTOMF,CH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against �j
liabilities,judgments.cost Vcxpensysyuch may in any way seems against said City AIR HANDLING UNITTO 10.000CFM)
in m...oincc of the g fl it. .
AIR HANDLING UNIT(OVER 10.000 CFM)
ignuture nl11 wKf
Date IiXHAUS'r HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITITO 100.000 BTU) Date Receipt#
Will the upplicanl or future building occupant store or bindle hazardous material IIIiATING UNIT(OVER 100,000 BTU) TOTAL:
as define by Ne Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Calc,Section 25532(al] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCEIDATE
pm
Will the applicant orfuture building occum use equipmentordeviceswhich emit BOILER-COMP(3HP OR 100,000 BTU) st PiD
41Wasardas.ir cormminams as define by the Bay Area Air Quality Management BOILER-COMP(OVER 1003000 BTU)
mrigt, -
❑Yea El No NEW RIiS1UliN'I'IAI.MIiCH. SQ,PT, SEX99
P 5
' I have read the hazardous materiah requirements under Chapter 6.95 of the �'� v�s77
-California I ImIth&Safety Cee,Sections 25505,25533 and 25534. 1understand That Ur Lt1_'
if the building does not currently have a tenant,that it is my responsibility to notify the
fupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
Owner or autlmri fed agent Date T ISSUED BY:�r�!
OFFICE