27095 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO m1:DING-ECECTRITA PBRMITNO.
APPLICATION/PERMIT PING FROG CIMECHANICAL
FICA 27095 7 O 9 C
BUILDING DIVISION HUILDINC.PROJI?CI'IDRNI'IPICA'1'ION L J
BUILDI DI iS$: SANITARY NO. APPLICATION SUBMITTAL DATE
/ J ITN LOT 0
O e 'NA v: PHONE CONT g'S MN LIC Sib
I (� /i �y N/C CONTROLp
• A C PTF. T D(NEER: IC NO: A Q J ❑
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CONT CT: Pxi
TY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE KX ❑ ❑ ❑
.ICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL fel
M=z IhembynlT m that lam licensed underpmvisinnso(Chupmr9(enmmmcing with JOB DFSCRIPI'ION
P400 Section WlIXOof Division 3 ofthe Business an�ofesoms Code.and my license is in PANELSfulrrsAAA
License
nseforClass
t. G
PzR! License Cluss�`-�-9 Lic.p� UP T0200 AMPS
Nay Dam Contra, 201-1000AMPS
F,zARCHITECPS DECLARATION OVER 10010 AMPS SQ.FT.FLOOR AISPA S/SQ.FT.
OZ ns 1 understand my plashop be used az public records.
P4 Licensed ProfessionalSIGNS ELECTRICAL
had
m< OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
�R�44'OaF I hereby nffnn that I oro exempt from the Contmmnr's License Law for the
ts1 ar ,r, following mason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
L,'J 0 which requites a Permit o conscuct,alter,improve.demolish,or repair any structure
f }� prior to its issuance,also requires be applicant for such Permit file a signed smement POWER DEVICES
WOO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(commencing with Section 7000)of Division 3 ofthe Businiosand ProfessionsCode) SWIMMING POOL ELECTRIC �S VALUATION
�
1Xy_y or that he is exempt dumfound and the basis for Ne alleged exemption.Any violation of OUTLETS 0'
4ectio
Section 7031.5 by any applicum fora permit subjects the applicant me civil penally of Off.
not more then five hundred dollars(S500).IY_� ❑ I,mownerofthe n NEW RESIDENTIAL E Q.Fr. STORIES TYPECONSTRUCHON
o propsyre is not
endrdwimwagesasmei(Sec,704,1,11 onew LE4T'R
a3o0 will dothcwons end the ho,Cmeismotimenense Law does not apply to an Business � /�� �s�o-4
add Professions Cole:The Cmnrzcmrs License ores such
not apply to ca owner of V/p,T.1 V'-
pmpenywhob,pwvirimpatsuthimprovednmonminiend hioffcmdtluauge.his OCG GROUP RFS.UNITS
however,the
improvement
mpr vemenpmaemcntserenotyearoldmoffeedthem oIf.
however,thebuildingnrimprovementishathwithinoneyear or improve will have the burden of that he did not buil or rove for purpose of
Al..
proving p pupro
ale.).
❑ Lns the project(Sou.70a14,Business
m licensed conanclorsm QTY. M TNG PERMIT FEE FLOOD ZONE APN
atmtmm the project(Sec.o an
Business and Pwhobiom Cale:)She Cemon.an's PERMIT ISSUANC.
License Lew does nm apply m an owner of property who bei Ida or improves merean,and
wAcme Law.sfnxuchprojecDN
wincommr(
raes)Iicensed pursuant ven
he Contractors
lice se LaALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑n1 mn exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SANITARY out Y ON
Owner Dote DRAINS-FLOOR,ROOF,AREA,COND. RECEIFI'q
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
1 barely offer met 1 have a cenifcae of consent to self-mean,ore certificme of RECEIPT g
Workers!C Fl%T31RPS-PER TRAP
penialllI��Insurencear.cenifiedcopY mereof(Sm.3g00,Lab C.)which PARK PEE Y N
rs all empl Ac'tmhde t. ^/ / ^ GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPfp
Policy g J ]—Gs BUILDING DIVISION FEES
❑m Certified copy is hereby fumishee r GAS-EA.SYSTEM-OVER 4(EA) PLANCI IIiCK FEE
❑ Cenilied copy is fled with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionnced not becomplemd ifthe permit is for one hundred dollars Bilho) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or lust
Icemb,that in the perf..o..fthe work for which this permit is issued,Ishall WATER HEATER W/VL'NT/ELI:CTR
mol employ any pmat in any manner so es m became subject to the Worker' PAID
Compensation Lawaof Cali(omia. Dns WATER SYSTEM/IRPATINO Dam ReceiptN
p z Applicant
NOrICE'TO APPLICANT:If,after making this Cenificne of Exemption,youshnuld NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
V) became subject in the Workers Compensation provisions;ofthe labor Code,you must
Ki forthwith comply with such provisions anbis pee n,shall be deemed evoked. BUILDING FEE, 040
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z Ithereby.fftmt thadno,is aaomauctiun lendingagency formeperformanceof
the work for which this permit is issd(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
P uaTinder's Name r PLUMBING FEF.
O U lenders Address QTY. MECHANICAL PERMIT PER
I certify t have d this application and state that be above infomtmicn is
correct.la eto comply uh all cityTA unty oNinences and arum laws mlatingm PERMIT ISSUANCE MECHANICAL FEE
I•" buildingr suuction,an hereby. repmscmnivea of thiscitymentnuponme CONSTRUCTION TAX
V z above- mioned ppeny far' tion puryosea. ALTL•R OR ADD TO MECH.
a).gree too".ve,' a fy end keep harmless he City of Cupertino against
-m,judgmems,c c pensee which may Iran way accom.painn said City AIR HANDLING IJNIT(TO 10,000 CFM)
c ucnre
ofm s go mtit.
AIR HANDLING UNIT(OVER 10,0001 CPM)
Sigmrw/,;--'cPC�-1P,mm.Municip!.�P
mnhaeer D EXHAUST H000(W/DUCO PAID
IAZARDOIJS MA'f.RIA CLOSURE. HEATING UNIT(TO Ifp1,OW B'fU) Data Rcceiptp
licant mfumre building y tst w.or handle hueardous anumal HEATING UNIT(OVER 100,000 BTU) TOTAL:
as deft .Chapter 9.12,and the HeuOh and Safety 1
TO
Code,Section 25532(.)9VENTILATION FAN(SINGLE RPSID)
❑Yes o
ISSUANCE
BOILER-COMP SHP OR 100,04111 BTU) 'DATE
Will the upplicam nPowrchuildingoccupanmseequipmem ordevica which emit k' W 1 iY
comm,,s air ronmminonm as defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
D;asriaSEP 3 0
❑Yes ❑No NI3W RESIDEN'f1AL MIiCH. SQ.FT, 1994
It a rend the honWom menial.requirement under,Chapin 6.95 of the
Cu ami.Health&Safety tions 25505.25533 and 25534. 1 understndmat Crll r yr l.urrnIHVU
to buildingdoes not have.board,that it is myrespansibility m notify the
m t of the requi as which must be met prior to isemnce ofm Certificate of
Ownerorautl d Date TOTAL: ISSUED BY:
OFFICE