27091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFC
F CUPERTINO °B¢DPKG.ELECITHcxL PERMITNO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT'IDEM I'IFICA'I'ION
91
BUILDING ADDRESS: SANHARYNO. APPLICATION SUBMFITAL IIA'IT
UNIT# I.OTN 3Lf
OW RS li: PIIONC: CONTRA 'S NAME: LIC NO:
al CONTROL#
C 1 ; 'DENGINEER: LIC NO: ADDRESS: ❑
PHONE: QTY x' ELL-. '" e' 4 PERMIT w FEE s BUILDING PERMIT INFO
'1 ' ECTRIC :'. ,
4v
PERMIT ISSUANCCEEBLDG ELECT PLUMB MECH
32.- dl IRI J0 ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
MWz Iherehyaffinn Nat lumlicens underpmvisionsofChapter9(commencingwith JOB DESCRIPfION
FJCq Section 7"Bof Division 3 ofthe Businessand Praminions Codgand my licenseis in PANELS
auk mu rine and Officer. --#�
FFZW License Class Lic.0 UPT02MAMN WO +TeV�. P17 L4/
tn?y Dam nt
Cunstua - 201-1000 AMPS S FT.FLUOR, ARFA S/SQ.FT.
Z0'— ARCHITECTS DECLARATION OVER 1000 AMPS Q
6 Z_G I understand my plans shall be used as public records.
r rn F W SIGNS ELECTRICAL
QY j Licensed Profession.) -
���Q OWNER-HUILDER DECLARATION SPECIAL CIRCUIT/MISC. nI1 T
XOyU I hereby affirm that I em exempt from the Contractors License Law for the _ 'J
W LLtr~ followiello-co.(Sectam ID31.5,Businessand PmRnsions Code:AnyeitYoreoumy TEMP.METER OR POLE INST.
Jwhich requires n permit to chnsvue1.alter,improve,demolish,or rtpdr anY swnure
Cad<5 to its issuance.alsomthea licant for such nofileasi statement POWER DEVICES
prior reyuires pp permi grncd _ , 11 ]
ty oJ' ps that he is licensed pua t to the provisions of the Conunefors License Law(Chapter � I 1 1, r
d o.oLL 9(commencing with Section 9000)of Division 3 of Nc Business and Professions Code) SWIMMING POOL ELECTRIC ` I, VALUATUNIP
Wed,, or that he is exempt herefrom and the banisfor the alleged exemption.Any violationof - 3
,ZQ Section]031.5 by any applicant for a Permit subjects the applicant to u civil penalty of OUTLETS-SWITCHES-FI%'NRES
nm more than five hundred dollars(SNXEL C NEW R DFNTIAL El Q.lel'.� ❑ L.asowncrofthe propery.or mycmployceswith wages as theirxmlecomp,marion. STORIES 'I YPH CONS I RUCt 10N
y 3. will Pr the wons and c:Ile wre i Consommes
License
a se Lae docs of salary 9oim owner of
and Professions Gale:TTc Contractors Licensee Law does not apply to w owner of
propcnywhobuildxor improves thereon,and who does such work himselforthrough his
employees,pmvidedthetsuchimpntvemenismenwintendedmofferedforsde.If, OCC.GROUP RES.UNITS
however.the building or improvement is.sold within one yemofcompletion,theowner- TOTAL' -OD
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner of Ne properY•am exclusively cnnuacting with liccnscdcontractors to QTY. PI. IN MIT FEE FLOOD ZONE APN
couseact the project(Sec.7044,Business and Professions Cede:)Thc Contrutor's
License Luwdocs not apply toanownerofpropeny whobullds orianproves thcrem,and PERMITISSUANCH
whoceareeds forsuch projects winhacontrector(s)Imemadipursaant to the Coatrenor's
License l.vi. ALTER (E
) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fur this Puma BACK FLOW PROTECT.DEVICE OUTSIDE EE.
SANITARY Y N
Owner Data COND
AREA,, . RECEIPT#
WORKMAN COMP FNSATIONDECLARATION DRAINS-FLUOR, SCHOOLTAX Y N
�c❑erars Compensation
Insave a urance
oraceri a corwrni it)pytherof(Snwre,uf Lab C.)c ne which
PI%TURKS-PIiR TRAP RECIiIPfp
Wmkers'CnmPenwtiun Insurance oracenilieJ copy thereof(Sow. Lab C)which PARK FEE YN
dl employee's unser this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FRES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK ME:,
❑ Cerieed copy is hereby furnished.
❑ Certified copy is filed with the city iaspredmidisebart. GRFASI%INDUSTRLWASTEINTF:RCEPfOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAI' SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne Permit is Peron hundred dollars SHR) SEWER-SANITARY-STORM EA.20g)P1', ENERGY 19717
n.)
I..1, that in theperformance,
ofthe for whichthisobject t is issuW,rkers WATER IiFATER W/VFNT/ELECfR
employ any pcann in any manatee so as to become subject rr the Workers PAID
Compensation laws of Cdifomia Date WATER SYSTEMlfRGTING Date Reccipsp
O z Applicant
z C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT'. TOTAL:
I--' fA become subject o the Worker's Compensation provisions of the Labor Code,you must
Ix 7 forthwith comply with such provisions or this permth
itshallbeemBUILDING I:EE edrevoked. 049
W F CONSTRUCTION LENDING AGENCY SEISMIC PER
I hereby affirm th
that them is a construction lending agency for e performance of
V Q the work for which this p.it is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ME 6q,
00
rr Lvtdef's Name
TY. MECHANICAL PERMIT FEE PLUMBING FEE
Lent I s Address Q
C1 1 certify that I have reed this application and vara that the above information is MECHANICAL FEE
corco.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
C' building consuunl anOwns,mpredervartives ofthiscity to enter upon the CONS'IRUC'I IONT'AX
L.) Z abovcanc el sm tics. ALTER(IRAODTOMECIL
remto sav City of CuPerinn against
"i'smdexp Otter Or,in any way as agninstsaid City AIR HANDLING UNIT(TO I B,Q•IfI CFM)
Oeg nu ION.
� AIR HANDLING UNIT(OVER IQWD CFM)
sijuoat Date EXHAUST HOOD(W/DUCD
PAID
I IAZARWUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Recnptp
W ill the applicant or future building mcuparn atom or handle housrdous matenhl TOTAL:
m Jcfred by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW.OW BT U)
Code,Section 25532(x)? VENTILATION FAN(SINGLE REMDI
❑Yes ❑No
ISSUANCE DATE
Willtheapplicantorfuture building awcupant use equipment ordeviceswhichemit BOILER-COMP(3HP OR 100,000 BTU)
zardnus air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A I 'D
Qinrin? -
[IQ
Yes ❑No NEW RFSIDENIA
'I' L MECIL SQ.IT. SEP 3 Q
1 have read the hazardous materials requirements under Chapter 6.95 of the 1994
Culil erect.Health&Safety Cole.Sections 25505,25533 and 25534. 1 understand that
if the building Dees not currently have a reason,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Cenificam of Cur V!'INVf<n 1 HvV
Occupancy. Y
Owner or authorized agent Date TOTAL: ISSUED BY. tnUce
OFFIC