27893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDELDTh7C-EIFLTRTCAI. PF.RMITNO.
BUILDING,DIVISION w w
APPLICATION/PERMIT PLUMBING-MP.CIIANICAL. 'LJ SVi
BUILDING PROJECT'ID"I IPICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2 NIT LOT L-Iti.-C 5
PHONE
LIC
;PFAJ
/' : ADDRE S
N/C CON'1'ROLpOWy /ma0
ARCHITECTA?NGINIFER: LICNO
CONTACT: PHONE:
QTY. ELECTRIC PERMIT F BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE � f< El
LICatlmiiENSED ONTRACI'ORSpECLChap DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz Ih700( Division
amf,ha Business
add isiomofn.Cock,
my]it.wish
LL100 Sectionorce and of Division 3 of the Busineu end Profesaiona Cade,end my liceme is in PANELS
qZW Licfullense
nse Claleffen.
F,ZW License Class Lic.p UP TO 300 AMPS 1
r. y Dam Catonctm 201-l""PS
ZOv'aZ ARCHITECTS DECLARATION OVER I000AMPS SQ.FT.FLOOR AREA MQ.FT.
O Z—C I understand my plans shall be used as public records.
F-as J LiSIGNS ELECTRICAL
. LicensedPro&asinnal
�a 6
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�N�(( :LL� I hereby affirm that I um exempt from the Convectors Liana Law for theto
v130 following ream..(Said.703 L5,Busine�.and Professirm Code:Anycitymeounty TEMP.METER OR POLE INST.
Om 5 which requires a permit m conswct,cher,improve,demolish,or repair any avucture
N,2 pd or to hs Issuance,slsorequirea theapplieamfar such pe.I,to fileasigned simemenl POWER DEVICES
yaj_�O thne
Bud he is limned!pit am mnurhe pmvisiona o
f the Convectors Lt..Law(Chapter
N 0E 9(commancing with Secuon7001pof Division 3 of the Business and Profession Cale) SWIMMING POOL ELECTRIC VALUATION
y or he is exempttherefromaod the basis forte alleged exemption.Any violation of OUTLETS-SWITCHPS-FIXTURES
GSection 7031.5 by any applicant for n permit subjects the applicant to a civil penalty of
not more then Eve hundred!atlas(551x1). NEWRESIDENTIALELECTR _SQ.FT.
❑ 6osown<rofthepropeny,nrmyemployeuwithwaguutheirsol<compenvuon. STORIES TYPECONSTRUCION
LLa_ will do the..it. it the structure is not intended indifferent for rade(Sm 7044,Business
and professions Cade:The Contractors License Law date out apply te an owner of
pmperty who hnills or improve.thereon,and who doe.such work himself or through his
own employees,provided that such improvements ot intended or offered forsale.If. OCC.GROUT' RES.UNITS
arer
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden ofproving Nat he did not build or improve for purpose of TOT
.ale.). QTY. PI. BING PERMIT FEE FLOOD ZONE APN
❑ Los an,project(Sm.
nntmdiimer Cdth e:)The Contractor's
torturerLica.1 the project ISN..anta Business end Rolbssiaaa Code)The th..
whocontracts
eyplymanowaerofpmperty whnsedpsoriourmthsthereon,end PERMITI ANCE
whoonseLo forsuch projects with acrmnctor(a)licensed punuennothe Crnvacmr's
License Law. A .R-DRAIN&VENT-WATER(LA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACKFLOW PROTECT,DEVICE D �•F"
SANITARY Y N
Owner Data RECEIPTg
DRAINS-FLOOR.ROOF, ND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N_
❑ IhereM1y affirm that]have ncertifieutc of consent to self-insure,rremrltateT RBCF.IPfg
Workers'Compensetiun lrtsumnce nracenified espy sherwf(Sec.38lN1,Leb .)whichch FI%TURES-PI?RTRAP PARK FEE YN
coven all employee's under this lamina. GAS-FA.SYSTEM-1 INC ET RECEIPT g
Policy p BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-O —?Y,0(BA) / PLANCHECK FEE
❑ Carried copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRI'ASFJIN WA, s .RC R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
('11assection need not he completed ifthe permit is furore hundred dollvs(SIM) SEWER-SANITA Y- TORM EA.2MP1'. ENERGY FEE
orlessJ
I certify that in the performance ofthe work for which this permit is issued,I shallNEATPRW AtLECTR
not employ any person in any murder so as to become subject to the Worker' PAID
Cnmpensetiur Lnwa of Celifomia. pate WATER SYSTEM/TREATING Date Receipt
0 Z A,hrom
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RES IAL PLMR. Q.FT. TOTAL:
V) become subject o the Workers Compensation provisions of the Labor Cale,you must
a foMwith comply with such provisions or this Permit shall be deemed marked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby affirm thin du re is e construction lending agancy for the performvrce of
V O the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC IEE
Lcri Name
0 U Lender's Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
L) 1 certify Nat I have read thin application and state that the above infomauon is MECHANICAL.FEE
correct.l agree to comply withal)city and county ordinances roof nate laws refiring to PERMIT ISSUANCE
I-' building construction,and hereby amhorica representatives ofthis city roamer upon the CONSTRUCTION TAX
VaMve-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
I Wn)agree to save,indemnify and keep harmless the City of Cupertino against
Ii bilitica,j dgments,costs and expenses which may in my way amour,against said City AIR HANDLING UNIT(TO 10,000 CFM)
it on. nee of the gracting
f this permit. p/ •O
�L AIR HANDLING UNIT(OVER 10,0011 CFM)
p t r at EXHAUST HOOD(WMUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,100 HTIH Data Receipt is
Will the applicant or future building occupant store or handle haturdous material
as defined by the Cupertino M unicipal Cale.Chapter 9.12,and the health and Safety HEATING UNITOVER 100,1X111 BTU) T
Cala Section 25532(e)7
❑Yea ❑No VENTILATION FAN(SINGLE REBID)
BOILER-COMP(3HP OR 100,000 BTII) ISSUANCE DATE
Will thI,contant erminous
as building by the ay AreaAen Quality
Management s�
harallous air comaminents ss defined by the Buy Area Air Quality Mrnagemem BOILER-COMP(OVER 100,000 BTU) �k7 p
DinricR nlI w'V
❑Yea 0 N NEW RESIDENTIAL MECH.—SQ,FT. q/1//y� h.
1 have read the ba7 rdous materials requirements under Chapter 6.95 M the �4//'''a -'/
California Health&Safe Code,Sections 25505,25533 and 25534. 1 undemand that k. a
if the building does not curnmly have a tenant,that it is my responsibility to notify the Uh- ��k9nS
occupant of the requirements which most be met prior to issuance of a Cmifmcate of V p
Occupancy. C
Owner m mahM ead.gent Data
TOTAL: ISSUED BY: