27279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BaeasEc+%-ME PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT )IN(,PPLUMING-MEcnANIFIC r
IIIIILUINF PROJKCI'IISF„4'1'11+KATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMD-I'AL DATE
IJ writ
10 Z)
O iRS ME: PfIONE: 1 CO CTOR'g NAME: LI NO: NIC CONTROLN
f1 E 1
A H CT/ENGINEM: LIC NO: ADR ESS: '� / ❑
CONTACT: PHONE: S BUILDING PERMIT INFO
_ QTY. LLECTRIC PERMIT FEC
BLDG ELECT PLUMB MliCfl
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Myz Ihereby affirm that l am licensed underprovisionaofChapter9(commencing with
P100 Section'1000)of Division 3 ofthe Business and Profusions Code,and my license is in PANELS
WV full tome and effect. UP TO 200 AMPS fbv ' aa
Zz, fall(fose rce
Lio.q
F 6 4 Data - Coa mrmr 201-1000 AMPS
f—o,Z ARCHITECTS DECLARATIONSQ.PT.FLOOR AREA S/SQ.FT.
C Z y 0 1 ondentana my plum shall be used m public mcoras. OVER 1000 AMPS
r y k W SIGNS ELECTRICAL
o: Licensed Professional
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOyU I M1ercby nfftm that I am exempt from the Can.,.,'.License Law future
µ!84,y following mason,(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which myairea a famish consaucL alter,improve,demolish,or repair any swnum
in prior m its issuance,also carp res the applicant(orsuch permit to file a signed statement POWER.DEVICES
fl
a00 that he is licensed pursuant the provisions of the Ctmoactar's Lio am,law(Chapter
2 y SWIMMING POOL ELECTRIC
de 9(commencing with Section Division Business and Professions Cade) VALUATION
�—y or that he is saempuherefrom and the basis for thealleged exemption.My violarionof OUTLETS-SWITCHES-FIXTURES
�,-�G Section]031.5 by pay applicant for a permit subjects ns the applicant to a civil Penalty of
g C not mare than rive hundred dollars($5001). NEW RESIDENTIAL ELECIR —SQ,FT.
Wer ❑ I,asownernfthcpmo ny,ormyemployeeswiNwagesastheirnolecompensation, STORIES TYPE.CONSTRUCTION
a will do the work,and the structureisnot intended proffered for sale(Sec.]044,Business
and Professions Cole:The Contmcmes License Law does not apply to an owner of
propersywho mnidaodmproves thereon,md shodasauchwork himmlforNmugh his
amp1pyees,provi pmv,mededthatsuchim ntsatenmintendedarofferedfmsde.If. OCC.GROUP RES.UNITS
on,
however,the have
the burden
improvement is cold e i i inoneyemo improve
thpurpose
o-
huilderwill have the burden of proving that he did not build or improve for puryom of TOTAL:
.ale.). QTY. PLUMBING PERMIT FEE CI DOD APN
❑ Las the prof oject(Sec.7( an exinsivelycnrofesiio with licensed Contintonro
deans, the project(Sec.oano Bastions and Profusions Code:)The Con40etar's
License Lawdoca not apply menowncona.vetty whosed famimpmvestherean,and PERMIT ISSUANCE
License Law.
for suchprojects withacamnvcror(s)IicenuA punuenuothe Cantnemr'e ALTER License Lew. (' FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-11.008,ROOF ,GOND. RECl:["#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsent to self-insure.or a ce"ficateof RECEIPTN
Worketa'Compareation Insurance or a rectified copy thereof(Ses.JIM.Lab FIXTURES-PCR P C.)which PARK FEE Y N
coven all employees under hia permit. GAS-EA.$ _ -1 INC.rj� ETS/
RF.CF.IP 0
Policy p BUILDING DIVISION FEES
Company GAS- t .SYSTEM-0 (EA) PLANCUECKFEE
❑ Certified copy is hemby famished.
❑ Certified copy is filed with the city inspection division. O ASE/INDU ' AS I CEPTOR GRADING FF.R
CERTIFICATE OF IDAIMPHON FROM WORKERS' R SOILS PER
COMPENSATION INSURANCE
(This section need costs,completed lithe permit is(iron,hundred dollaes(fIW) S WER- A ITAR -STORM EA,2 ENERGY PEE
or less.)
I certify that in the famb .ace of the work for which this permit is issued,Iehall W RHEA TER WNENT/HLE
nut employ any person in any mannas to as to become subject to the Workers' PAID
Compensation Lawsof Califomis. Date WA RSYSTEM/PREATIN Date Receipt#
0 Z Applicant
Z 0 NOTICE TO APPLICANT:If,niter making this Carficam of Exemption,you should NEW ESIDENTIAL PL;A. SQ.Pf. TOTAL:
rbecome subject to the Workers Compensation provisions of she Labor Code,you must
ter' > forthwith comply with such provisions or this permit shall he domed ervoked. BUILDING FEE
L3J [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby uffimt that them is a consfaction lending agency for the performance of TOTAL: ELECTRIC I'EE
O lbs,work for which this pnmit is issued(Sec.309],Civ.CJ
O Isnder's Name PLUMBING FEE
llndrA Address QTY. MECIIANICAL PERMIT FCB
1 canny that I have mad this application and soon that the above information is MECHANICAL FEE
off” comet.l arms,to comply with all dry and county ordinances sad state laws mating m PERMIT ISSUANCE
building construction,end herebyauthpme mpreacnnfivesofthiscity 0terupon the CONSTRUCTIONTAX
V above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save.indemnify and keep hemdess the City of Cupertino against
liuhi11';Iijudgmen t5,costsan es which may in any wayaccrue against said City AIR HANDLING UNIT(TO UMM)CFM)
in ca se ase eating his rmir. AIR HANDLING UNIT(OVER 10,00)CFM)
tsiii of Applicam/Contmcmr Date EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt If
Will the applicant or future building accupanr same or handle hazardous matenal HCATINO UNIT(OVER 100,000 BTU) TOTAL:
its defined by the Cupari no Municipal Cole.Chapter 9.12,and the Ileahh and Safety
Calc,Section 25532(.)/
11 Year ❑No VENTILATION FAN(SINGLE RPSIU)
110I1ER-COMP(3HPOR 103,0(10 RTU) Rq 1$SI�A NCE DATE
Will ncevpplicant orfmurt buildingoepa
cuntuxern
quipmt or devicexwhichemir Ir Q{ u
hanrdous air conuminams as definW by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0001ITU)
Garcia? El 1
❑Yes No NEW RESIDENTIAL MF.CH. SQ.FT. J(]/]n
1 have mail the nuardous materials reyuimmems our,Chapter 6.95 of the �'�� Uri JJf�
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that V r,
if the building does not currently have a tenant,thin it is my mapnnaibility to notify th< laUYth11 INV
occupant of the reyuimmenrs which must he met prior to issuance of a CMfocam of
Ocrupancy.
Owner or authors zed.gent Dataal, ISSUED BY:
OFFICE