27646APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING -ELECTRICAL-
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENI NICATION
PERMIT NO.
27646
Bp LDING ADDRE/yS�S/ly�
NSW MIT LOTM
SANITARY NO,
APPLICATION SUBMITTAL DATE
111
PVIF PHONE:
CON'JyAC1Y)R$ A LIC NO:
❑
CON RROLN1,
�OWNIV
J`' r�
ARCA 1'I fiCUENGINHER: LIC NO:
ADDRESS:
CONTACT': PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG PLUMB MECH
PERMIT ISSUANCE
0 Kj
LICENSED CONTRACTOR'S DECLARATION
herchyaffirm Nat I am licensed under pmvisiomof au,nor9 (comrsomm, wird
APPLIANCES- RESIDENTIAL
10B DESCRIPTION
i Section 70(10) of Division 3 of the Buxness und Pmfosslons Cade, and my Eceme is in
full to. and effect.
PANELS
'• �g
License Class Lic.N
UPTO200AMPS
,
Date Contractor
201-IDW AMPS
ARCHEMCPS DECLARATION
1 mulecsmnd my plane shall homed., public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL.
Licensed professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUTDIv C.
I hereby affirm that 1 sure exempt from the Commences License Law for the
TEMP. METER OR POLE INST. /as
following reason. (Section 7031,5, Business and Professions Calc: Any city or county
which requires a Pmain to comwcL alter, improve, demolish. or words any stmc i m
prior to its issuance, also requires the applicant for such permiuo file a signed saumem
POWER DEVICES
that he is licensed pursuunt to the provisham of the Convectors Liceme Law (Chapter
9(commencing with Section 7") of Division 3 oohs, Business and Professions Code?
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt herefrom on([ the basis for the alleged exemption. Any violmionof
Section 7031.5 by ay applicant for a permit xabj.0 Ne applicauo a civil penalty of
OUTLETS - SWITCHES - FIXTURES
t mare than five hundred dollars (85(1().
n❑ I,mownerafthc pmperty,ermyempenyceswBhwegcsmthei(See camperumion,
NEWRESIDENTIALELECI'R _SQ.FT.
STORIES
PP. CONSTRUCTION
not 'm nded ed Business
do Newons and thestructureContractor's
and
and Cale: The Cornmessm, License Law does net apply lf an owner of
kende ata dos not apply to an
ortywsions
propertywhobuildsorimprovesthereon,endwhodonsuch work roseIfser though his
awn employees, provided that such impmvemenuarc notintendedoruffemdl'msale. If,
OCC. GROUP
RES. UNITS
however, the building or improvement is sold wlthmoneyear ofixurplerion. Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY' PLUMBING PERMIT FEF.
sale.).
[II,mownerofthepmpmy,emexchusivelyem clingwiNlicensedconmetonto
FLOOD ZONE
APN
ongmn Ne project (Sec. 8144. Business and Professions Code.)'Me Contractors
License L.uwdoes not apply to aowmerafp nary whobuildsarm,nowas Nnson, and
PERMIT ISSUANCE
whacontr isforsuchprtjenswithaeommtors)licensMpumuenl rothe Conuanor's se Law.
License
ALTER- DRAIN&VENT - WATER (PA)
FEESUMMARY
❑ l ern eacmpt arrear Sec. B & P C for this reason
BACK FLOW PROTECT. DEVICE
ou
TsibRFEESSANITARY
Y N
RFCEIPTp
OwnerDem
DRAINS - FLOOR,ROOF. AREA, COND.
WORKMAN COMPENSATIONDI3CIARATION
SCHOOLTAX Y N
❑ I hereby afOrm Nat l have a certificate informant a selLinsure, ma cerdfimte of
Workers Cnmpenwtion Insurance nrecenifW copy Nercmf (Sec.3g00, Lab CJwhich
RfCF.IPTN
FIXTURES - PER TRAP
PARK FEE YN
covers all emphayee's under this permit.
Policy N
GAS - EA. SYSTEM-] INC. 4 OUTLETS
RECEIPT g
BUILDING DIVISION FEES
Company
GAS- CA. SYSTEM OVER 4(EA)
PLANCHECK FEE
❑ CeniOW copy is art furnished.
GREASFJINDUSTRL WASTE IN . OR
GRADING FEE
❑ Comfort copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASC TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - A. 200PT.
ENERGY FEE
('this section need not becomplOW ifthe permit is fororshondreddollan(SI00)
or loss.)
WATTiR HEATFRW eLF.CfIt
I anti ry that in the Performance of the work for which Nis permit is lamed. I shall
.at employ any person in any mean so as to become subject to the Workers
PAID
Compensmhmal.uwsof Culifomiv. Data
WATT S EATING
Data Receipt
Applicant
NOTICE TO APPLICANT': If, after making this Cenifcare of Exemption, you should
NEW REST LPLM B. Q. ET.
TOTAL:
becamsubject e subjeco the Workers Compem.ation powishoeu of the Lahr Cade, you must
foMwiN comply with such provisions or Nis pcait shall be deemed revoked.
BUILDING FEF.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is v construction larding agency for the Performance of
Ne work for which this permit ha issued (See 3097. Civ. C.)
London's Name
TOTAL:
ELECTRIC FEE
Lcadno Address
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read Nhn application and state that Ne above informedon hs
coorem legrce mcamply with all city and county ordinances unJ stmc lawsrelatingm
PERMIT ISSUANCE
MECHANICAL FEF.
building construction. and hereby outhotize represem advesof this cfty m career upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MF.CIL
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino eg.fast
IiabBidix,judgmenu,cmu andexpeman whichansy many wsyaccmeagamit said CityAIR
HANDLING UNIT (TO ILDW CFM)
in consequence of the granting of this permit.
' z
AIR HANDLING UNIT (OVER 10,000 CFM)
t2a7h
Sign of Applicant/Contractor Of
EXHAUSTHOOD(W/DUCD
PAID
HEATING UNIT(TO ]BLOW BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt N
Will the application or future building occupant Mon or handle hazardous material
as defincN by the Cupertino Municipal Cade, Chapter 912, and the I{mIN and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
25
Cade, Section 25532(01
❑
ElYee 11 Na
Will Neu plicatmfature buihdingeccupam mac ui
p q Proem mdcvices which emit
1SS U TE
BOILER- COMP CHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
hemrdims air canwminana as donned by the Buy Arca Air Quality Management
Diatdn7
®/)
JAN
❑ Yen ❑ No
�^^�
P1tV 16 i7 any
NEW RESIDEYfIAL MUCH. SQ. FT.
1 have reed the heaardous materiels requirement. under Chapter 6.95 of the
CITY Ur UUPEN PINO
California Health & Safety Code, Sectiam 25505, 2553 uad 25534. 1 understand that
if the building does not currcn0y have a tenet, that it is my responsibility to notify the
accupant of the requircmcnts which most he met prior to issuance err a Cenifmts of
Occupancy.
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE