27591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO IRALIHNO-KL1[CPBTCAT, PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANIC 1, 1
BUILDING PROJECL 1I EN'II FICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l SL ca VKI- UW1 UNIT# LOT4
OWNI�B N^�M9� _ PHONE: NTRACO 'SNAME: LIC NO:
G aYaFxiYa 1P\ �. NIC CONTROL#
IARCIIITETCT/ENGINEER: LIC NO: DR S: ^ ❑
ONTACT: PHONE V
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMITISSUANCE IL�Yp� LQ
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
KZ Ihertbynffirtn that lvm licensed underproviaionsmfCTepter9(commeruing with
00 Seaion]B(I(D of Diiision3af the Business and Professiom Cade,and my house is an PANELS `/s ✓�
iy full force and effect.
a Z License Class Lic.# UP TO 200 AMPS
H=y Dm Contractee 201-1000 AMPS
CZ— ARhall he
DECLARATION R f/
OVER 1000 AMPS
O Z ❑ 1 undersmnd my plans shell be u.A as public records.
SIGNS ELECTRICAL
Licensed Professional
a'C�6
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�Nci5 m�� ; I hertby n.(Se that 1 an exempt from the Cocoons Co License Lew for the
t++3pm fallowing sauson(Section 7031.5,Business and Profusions Cade:Any city or county TEMP.METER 00.POLE INST,
oo which rvquirea a permit m construct,alter,improve,demolish,m repair any swctme POWER DEVICES '
ee�� pnormits issuance,also requires the applicant forsuch Permit to file a signed stamens
ty C) that he is licensed parmard to the provisions of the Contractors License Low(Chapter
9(commen6ng with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION a�
W.—m a,hat he is eaempt therefrom and the basis for thevlleged esemptinn.Any violationof OUTLETS-SWITCIICS-FIXTURES
E Q Section 7031.5 by any applicant far a permit subjects tha applicmt We civil Penalty of
not mom than five hundrtddollera(551X). NEW RESIDENTIAL P.LECIR _SQ.PI'.
13I,esnwnensfthepmpcny,ormy empinyeee with wages as lheirsolecampemedan, STORIES TYPE CONSTRUCTION
S will do the work,and the structure is not intended oroffearI foreale(See.70144,Business
and Profusions Cale:no Contractors License Law does not apply to an owner of 1.
Property whobuildsorimproves thenad,andwhodoes suchwork himselforduough Ns
own employees,powided that such improvemcnteanenot intendederofferafmaale.If, OCC.GROUP NES.UNII'5
however,the buildingor improvement is sold within one yea ofeempledon,the owner-
builder will have the burden of proving that he did nm build or improve for purpose of f
sale.).
❑ borawool.(thepmNmy,amexclusivelycon=tingwithlicnu .ntr¢torsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pnjeet(Sec.7044,Business end Rofeasirms Code:)The ContreCor'sPERMIT ISSUAN
License Law doe...tapplytovnaw....f property who bailcis m improves thereon,and
who contracts for such pmjmts with v contractor(s)licensed pursuant to the Contractors ALTER-DBA &�11T-
Liccr)se Lew. WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PRO CT.I E SANITARY DOLS D ES
N
Owner —Data— DRAINS-BOOR,ROOF,ARIA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihesabyalfrrtn shat l have a certificate ofeorrsent to self-insure.ora ced]ficateof FlXTIIRES-PER TRAP RECEIPTp
Walkers'Compenutimimumnceorecenifedcopythertaf(Sm.3801 CJ which PARK FEEY N
coven ell employed,undo this permit. GAS-EA.SYSTRM.I INC.4 OUTLETS CF.
Policy# BUI NJ OlIkIlIONFEIS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK MnO
❑ Cenified copy is hereby furnished.
Cl Codified copy is Bled with the city Inspection Elvadon. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FE
CERTIFICATEOF'EXEMPTION FROM WORKERS' GREASETRAP SOILS
COMPENSATION INSURANCE
(This section need not be,completed ifthe Permit is for one h dreddolla (SIM) SEWER-SANITARY-STORM P.A.2MPT. ENER `
in lass.)
I certify that in the performance ofthe work for which this pe I ,I shall TER CRATER WNENTJELF.CTR � O
not employ any person in my manner arm m become cc a.
Wo PAID ...
Compensation Laws of Culi(omin. Dam ATER SYSTEMaRIiATINGReceipt#
Z Applicant Yale
NOTICE TO APPLICANT:I1;after makid ani eof Exem ash d NEW RES]DENTIAL PLM. SQ.FT.
,z TOTAL:I� r D
tibecome subject Wnrkera Compensvtionp v ns of the y,you must
� , forthwith comply with ouch provisions noble pe it hall he da ked. BUII.DI .E r1
kol
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE �r
z ]hereby affirm that them is a construction lending agency for the Performance of
L) O thework for which thispatent is issued(See3097,Civ.C.) T ` ELECTRICFEE `
Leaders Name
OF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
V I certify that I have mad this application and auto that the above information is
Lid correct,l agree to comply with all city and county odarnmea and situ laws saluting to PERMITISSUANCE tea. MECHANICAL FEE
I^ buildingconameeion,and hereby maturire apiesentstivesofthis city to enter upon the CONSTRUCTIONTAX
V z above-mentioned property for inspection purposes. ALTER OR ADD TO MSCI I.
Me)agree to save,indemnify and keep harmless the City of Cupenina against
limilities,judgments,costs and expenses which may in any waycerueagnenossid Ciry AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the greeting of thia permit.
/- AIR HANDLING UNIT(OVER 10,0110 CFM)
Signatureof Applic omrnm - ——1
-Dt,7 EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.)10(1 BTU) Date Reaip
Will the applicant or future building occupiers store or handle haaardous material HEATING UNIT(OVER 100,0013 BTU) TOTAL:
m defined by the Cupertino Municipal and l Cade,Chapter 9.12, the Health end Safety
Code,Section 25532(.)7
❑Y. CI No VENTILATION FAN(SINGLE NFSID) PIA
1 Will the appilicantor fuwrtbuildingmcupum uaeequipmcntnrdevices which emit BOILER-COMP(3HP OR I(p,IKKI BTU)
UWCE DATE
\ heamdous air contaminants as defined by the Bay Area Air Quality Mmngement BOILER-COMP(OVER 100,000 BTU) ��� 1 Q 1���
District? V
❑Yea ❑No NEW RESIDEM'IAI.MFCII. SQ.FL s7y
1 have motel she bmnlons My materials requirements under Chapter fi.95 of the CI I I Uf UU(-'t(-(I INU
Califomiu Hauldi&Safely Cale.Sections 25505,25533 and 25534. 1 aua.smnd shat ^
if the building does not currently have a tenant.that it is my responsibility to notify the
occupant of the requircmants which must be met prior to issuance of a Certificate of
Occupancy.
Owner or aullimizcd.gent Data 'f IfSUF.D RY:
OFFICE