27900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
jBUILDING
FCUPERTINO IIIJ S-F.L.CI'RICAL PERMITNO.
DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 7(]0 O
BUILDING PROJECT IDENTIFICATION I J
ADDRESS:////�//J1 ('/J// �/� SANITARY NO. APPIdCATIONSUBMITALDATE
�(//s®JrCI-�/VY� UNITp LOTHAME: . PIfON �- A� OR's NAME: LIC NO: N/C #TROLENGINEER: LIC NO: JJ DRESS: _ J1 ❑
CONTACT PHONE.:
QTY. ELECTRIC PERMIT FEEHULLOING PERMIT INFO
PLT: UMB MECII
PERMIT ISSUANCE tow
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz Ihereby uffinathai l an licensed underpmvismawfatifter9(comanamingwith LOB DESCRIPTION
4p W Section 7Q9)ofeDivisiontJ of the Business end Professions Cade,end my license is in PANELS
FCU Licensfull eeandeffecf.
QZ Lianx Class Lic.p UP T0200AMPS
y6y Dme Commctor 201-I"AMPS
ZOriiK ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $)SQ.FT.
C z-m l undersmnd my plans shall Its media public recards.
i SIGNS ELECTRICAL. 1y
CC Licensed Professional —`
OWNER DECLARATION SPECIAL CIRCUIT/MISC.
XOiU I hereby affirm that I an exempt from the Contractors License Law for the
Wan H followingresson.(Section 7031.5,Business ad Proessions Code:Any city memory TEMP.METER OR POLE;INST.
�!i:ON J which requires a piano[to conrrun,aper,improve,demolish,or repair any structure
C }� prim to its issuance,also requires the applicant forsuch Permit o file a signed statement POWER DEVICES
.'<0 that he is licensed pursua t to the provisions of the Commences License Law(Chapter
n Xa�- mencing
W 9(comwith Second 700T.fDsismat 3ofNe Business and Profeuimis Code) SWIMMING POOL ELECTRIC VALUATION
�_ra or he is exempt therefrom and the basis for the alleged exemption.Any violation of UTLETS-SWITCIiES-PI%9'URES - ; I 0
NTI
4 Section]031.5 by any applicant for o permit subjects the applicann...ivil penalty of
onot marcthan OvehundreA dnllnrs(85(Nll. NEW RESIDEALELECfR _SQ.FC STORIES TYPE CONSTRUCTION
C3I,asownerafthepropeny,ormyemployeeswithwagesastheirsolecompensution,
will do work,and the structure is not Intended minimal basale(Sec.7144,Business
—�
and Protestant;Cade:The Conuucmr s License Law does not apply to an owner of
propenywhohuildhorimpmves lhercon,anJ whodoes such wmkhimselfnnhrmgh his OCC GROUP RES.UNITS
own employees,Providedth d such improem
vents me nntimendd or
eoffered formle.If,
however,the building or improvement is sold within one yeerofomplina,Iheowncr-
builder will have the burden of proving thin he did not build or impmve for purpose of
Ie.).
❑ Ln nwnerafthe properly.emexelusivclyconwningwifhlicenuAconwnorsro QTY. PLUMBING PERMIT NEE Fi00DZONE APN
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's PERMIT ISSUANCE
Licenaal.uwdoesnotapplytemowneroflrtopcnywhobuildsarimpmves fiction,end
who comrmfs formch projecn with u contrutmoficerac ursminawhe Commcmr'a ALTER VENT.WATER(FA)
License Low. PF.E SUMMARY
❑ I um exempt under Sec. ,B&PC for this mason1:
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dam DRAINS-PLOORROOPARFAGONDRECEIPT#
. , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IhaeM1y affirm lhatl haveeanificem of consent mull-instate,ore ttrtificvm of RECEIPT
FWURES-PER TRAP
Workers Compensation haturnce oracenified copy lhereaf(Sce.3800,lab C.)which PARK FEE Y N
coven all employee's under this permit. GAS-EA., RECEIPT N
Policy N SYS INC.4 OUTLETS BUILDING DIVISION FEES
Company GAS-EA.SYS'T'EM OVER 4(EA) PLANCHECK FEE
❑ Cenified copy is hereby famished.
❑ Cenif¢d copy is filed with The city inspection division, GREASrONDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXI3MI?ION I-MOM WORKERS' GREASETRAP SOILS FEE
' COMPENSATION INSURANCE
(na,cnion neednm b rmad,leted ifthepernad isfrronehumdreddollurs(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE `
or less.)
I fl., hat in pto my mad thea us Wr whichthisbject as the W l kers WATER HEATHS W/VENT/13LECfR
norCo employ my person to any manner so as w become subject m the Workers' PAID
z Compensation Lewy of Celifomia. Date WATER SYSTP.M?NIiATING Uam Receipt
AOTICm
Z NOTICE suOAPo the Workers If.after Compensation
thisCisions o of Labor lode. oshould NEW RESIDIiMIALPLMB. SQ,FT. TOTAL:
H > becomeh comply
The Workers Compensation provisionsofthe labor Code.you must
� ; forthwith nrmply with such provisions,or Permit shall be deemed invoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby affmn that them is a construction lending agency for the performance of
V O the work for which this Permit is issue([(Sec.3097,Civ.C.) ELECTRIC ME r�
ILJy rr Lenders Name
F- Lenders Address Q'I'Y. MECHANICAL PERMIT FRE PLUMBING FEF.
I U I certify that I have read this application and spm that the above information is
correct.l.,ream comply withal city end countyordinances end state laws mindag to PERMIT ISSUANCE MECHANICAL FEE
F-' Ln buildingesmsmuction,and hereby awhorimnposea Ives ofmiscity to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection papxr. a. ALTERORADDTOMECIL.
(We)agree to save,indemnify ad kap hu picas the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue againss mid City AIR HANDLING UNIT(TO 10.000 CFM)
in co ce the gmn)ing off ' mriL - a. AIR HANDLING UNIT(OVER 10,000 CFM)
f
$ignlumaApplicant/Conmom Da/Iles' EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI'1'(TO 100,000 BTU) Dim Receipt#
Will the applicant or future building occupunt store or handle hazardous material
its defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532001 VENTILATION PAN(SINGLE RESID) 01
❑Yu ❑No IT
tx Will this colas ands.cleirad by the Bay Ana
Air Quality
Manachem i
BOILER-COMP CHP OR 100.000 BTU) ISSUAN
Distrdom is contaminants u defined by the Bey Area Air Quality Managetllrnl BOILER-COMP(OVER 100.000 BTU) f1�
District? V" p A ID
❑Yea ❑No NEW RESIpFNI'IAI.MECII. SQ.FT. H g
1 have mail the hamNous materials requirements under Chapter fi 95 of the ��)�
California health&Safety Code,Sections 25505,25533 and 25534. 1 understand that ) V to'D j^
If the bre id,ng daen
eenot currtly havuamnant,thm h is my maponsiM1m Ty/
l lily notify the Y/ y
n:cupool of the mquiremoms which most be and prior to issuance of a Cmificme of iq Y
Occupancy.
Owner or authorized agent Dole TOTAL: ISSUED BY: /
OFFICE