27358 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL ;NG-ELEUIRICAL PERMIT NO,
BUILDINGOC DIVISION APPLICATION/PERMIT PLUMB NO-MECHANICAL 27358
BUILDING PROJECT IDENTIFICATION
.WRLDING ADDRESS: SANITARY NO. APPLICATIONSUBMTTALDATIiI
to �V UNIT# LOTH
NERS;A,MC: ^ PITO is 121 C. fRACTORA LIC NO: N/C CONTROL#
ARCIII'HiCT/FNGINEHH: LIC NO: A R g pvE
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FCC
BL ELIiCT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ^L—
I hereby affirm that l amlicensed under mvisionsofCho t )(mmmencin th � DESCRIPTION
❑K2 Ya P per' gwi
400 Sectiorce itcfDivision3of the Business and Prafcssimm Cale,and my licemeis in ppryElS
Call ec�
License
Class f.,. irf a y
6-l{, License Class hic.p UP T02W AMPS
on Data Dato Corrector 201-I(NNIAMPS
ZONK ARCHI'1'EC`PS DECLARATION OVER I""Ps SQ.FR FLOOR AREA S/SQ.Ff.
OZ-0 I understand my plans shall be used as public acorea.
P'4t j SIGNS ELECIUCAL
y f-] Licensed Professional
W�'Q OWNER-BUILDFR DECLARATION SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt from the Committers License Law for the
m 3 a y following rTE
eason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MER OR POLE INST.
k a O which inquires a Permit to construct,cher,improve,demolish,Or rtpe'v any structure
mm or its issu acqulsn requires theliNlicaut for such pe.It to fileasigned swtemrnt POKER DEVICES
II+r1l g G O thin he is licensed pursuant to the provisions of the Contactors License Low(Chapter
a .Pc 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'T'ION
Moo m fan he is exempt therefrom and the basis forth,alleged exemption.Any vialationof
ZQ Section 7031.5 by any applicant for a pcmdt subjects the epplicannoacivil penalty of UTLETS-SWITCHES-FIXTURES
or more than five hundred dollars($5W). NEWRPSIDENTIALELECTR _SQ.FT. �V
�j�p^q' n❑ I,nsnwnerol'Om prnpeny.nrniyemployceewith wagesas Neirsolncompensut o., STORIES TYPE CONSTRUCTION
I y ae will Jo the work,und the strvcture isnot imendedoroffered formle(Sec.7044,Business
and Professions Cale:The Committees License Law does not apply to an owner of
pmpenywhobuildsorimprovesthereogand whodoessuchwork himselfortheaugh Ns
employees,provided tbut such improvementsam not intendedoroffemd forsole.If, OCC.GROUP RBS.UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder oil I have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I.asownerurthe propcny,am exclusively contrsningwith licensed cnntanors w QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construes the proj,n(Sec.7044,Business and Professions Cale)The Comment's
Licenxe Law does not apply wammwnerofproperty,wh.bLildso,improvest,rumi,and PERMIT ISSUANCE
who contracts forsuch projects with ucentactons)licensed pursuant to the Contractors ALTER ([A)
License Law. IEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this meson BACK pLo W PROTECT.DEVICE .IDEMES
SANITARY YN
Owner Dole DRAINS-PLOOR,ROOP,AREA,COND. RECBIPT#
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX y
❑ Ihertby affirm thatihaveaccnifiaete of camcm Wulf insum.oracenir..a.f 17XTURFS-PER TRAP RECEIPT#
Workers'Compensation Insurance rata rmified copy theresef(Sec.3800,Lab C.)which PARK FEE Y—N
—
covers all employee's under this permii. GAS-FA.SYSTEM-I INC. OUTLETS RECEIPT N
Policy N BUILDING DIVISIO
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ceaifiedcopyishercbyfumished.
11-3 05
❑ Gratified copy is filed wiN the city inspection division. GREASUINDUSTRLWASTEINTERCE OR G11kDING FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP SOILSEE
COMPENSATION INSURANCE
(This suction need not becompleted ifthe permit is farms,hundred dollars($I00) SEWER-SANITARY-STORM .200[7. ENERGY EE
orless.)
I cenify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VHNT ECTR
nm employ any pe.,a in any manner so as to bacome subject to the Workers' PAID(—,
Compensation Luwanf Califomia. Date WATER SYSTEMOREAT GReceipt.
O z Applicam
Z 0 NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PI. B. SQ.11R. TOTAL:
r-h fq become.abjectto the Worker's Compensation provisions of the Labor Cade.yon must
� � forthwith comply with such Provisions or this permit shall be deemed revoked, EO., Q CONSTRUCTION LENDING AGENCY L Vzo
Vz1 hereby affirm that there is a constructionInding agency forthe perfoomnce ofthe workfor which this permit is issued(See.3097,Civ.C.) O I.: E IYE Lender's Name FEE0 fenders Address Q'I'Y. MECHANICAL PF.R 1.I agrethin I nave ted this ity and cou and statethin Ne shove information is
h�" 4muco,es Cocom 1 tM1 all cit dentin rdinances and umelantrelmin w PERMIT ISSUANCE L FELgree pywi yon yo gUabove-gconstuaionanJhcri nspechnnpin-presemmivesafthiscitymcntruponthe 10N TAX
L) z nWv We)
proPerly for purposes. ALTP.RORADD TOMCCfI.
(Wc);t ,,andlCodma`,�,�Ign�
nt rove,indemnify and kap harmless the Cityen Cupertino against
liabilitia,jus,cine anich may in any way accrue against said City AIR HANDLING UNIT(7010,000 CFM)
in co q t a fill
/I AIR HANDLING UNIT(OVF,R 10,WO CFM)
ig to oorE�' Dale B%HAUSTHOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT To 1W,1KK)BTU) Dam eceegsp
Will the applicom or future buildingocctiestil or hundlehurtdousmaterial HEATING UNIT(OVER 100,000 BTU) IDT .
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a7?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
_ BOILER-COMP(311P OR 1 00,000 BTU) ISSUANCE DATE
winata appbaanl mrrawrena0aingmapmm mseegnipmrnt nrne.mea wnien emh
=m7Okca air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
�isviP n PY I D
❑Ya ❑No NEW RESIDENTIAL MLC11. SQ.fT.
e
I have read the hazSafety
Code,
materials res 5.2553 is Under 34,Chapter uereti ld the
Californialhealth&Safety Coda Semite 25505,25533 and 25534. 1 understood that FE
if the building dins dr currently have n must
Ise that o is my responsibilityancof
to nmify of
cupum of the ryuircments which must be met prior to issuance of a Certificate of
Occupancy,
H
- !� f'tf I NQ
Owmn a,authorized gem Data TOTAL: ISSUED B
OFFICE