27377 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO .°TMng-hI.EUIRT . PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEMITFICAI]ON 27377
BUILDII/�
N�GADD`RESS: � A
SANITARY NO. 'PIC�ATIONSUBMITTALDATE
V� �Z NIT# �� 4.
O N HIS PHONE: COM A LIC NO:
5 N/C CONTROL Is
A HTfECT iNGINEER: hIC NQ: 240 ADDRESS: ❑
CONTACT: / D BUILDING PERMITINFO
(� QTY. ELECTRIC PERMIT FEE
ELf.cT EC
hh2o -� X ,
PERMIT ISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
n of I hereby affirm that l am licensed under provisions of Chapter (commencing with
FDOOV�. Section 1000)of Division 3 ofthe Business and Pmfearions Code,and my limits is in PANELS
p;dfp full force and effect.
G ��200 � 1
W License Clore Lic.M
y<y Date Contractor 201-I"AMPS
ZOv2; ARCIIITF.CTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—p I understand my piens shall be used as public records.
I=ceY�; SIGNS ELECTRICAL elm
9Kw< Licensed PrNcfsianal
OWNER-BUILDER DECLARATION
nSPECIAL CHHULIM/MISC.
O F I hereby umnn that I an exempt from the Contractors License law for the
40Q following reason.(Section)831.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
ce.] which ermines ape.!!m mrstmn,ulcer,improve,demM ish.or repair anystrueturc
r^>� prior to its issuance,also inquires the applicantunlatch penniuo file a signedstatement POWER DEVICES
call C¢O that he is licensed pursuanno the provie' v of the Contractors License Law(Chapter
QQE 9 lcormnencing with Section l wition 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
�'^y anM1m he is exemptth ro dthe basis for the alleged ex<mption.My violation of //'•�^ ��
��¢ Section 1113 LS by any op 'v fornpermit subjects the applicant toe<ivil perWry of OUI'LETS-SWITCHES-FIXTURES
S SS¢S� not momthun ' n lormyempl NEWRFSIDENTIALELECrR _SQ.FT.
Wm ❑ I,aaownera up y,ormycmployecswithwegerastheirsolecompensntion, STORIES TYPECONSTRUCTION
L willdaahework a mcture is not iatendedoroffcmd forsale(Sm.7W,Business
^ and Probe. in C : The Col Columbines License Law does not apply m an owner of
propertyw b rimpmvesthet n,endwhodmssuchworkhim lforthmughhis OCOGROUP RES.UNITS
nempl videdthatsuchimprovement mnmintend oroffcm(mWe.Lf,
hewn ub l er improvement is sold within one yearofcompletion.theowner- T �.
builder will hav th human ofproving that he did not build or improve for purpose of
le.).
❑ Lasownmo epropeny,am exclusivelycomracting with licensedcnn"Inam QTY, PLUMBING PERMIT FI7E FLOOD PONE APN
contact the project(Sm.1(l44,Business and Professions Code:)The Contractor's p[RMIT ISSUANCE
License Urwdmanot apply to nn ownerofpmpeny whobuildsmimproveatherem,and
whoanmracts for such projects with scintillations)licensed pursuant mthecantrumr'e pLTBR-DRAIN&VENT-WATER(EA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this rteson BACK FL PROTECT.YBVICH SANITARY OUTSIDE
N
Owns, —Data— RECEIPTp
• DRAINS R,R ,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ y afm that i te incongruent elf inmrt,me artiBate oRECEIPT M
Workers CompensationInsurance oracerified copy thereoIS -PERTRA
PARK FEE Y N_
covey nil cmployca's under this L RNAEISK&
pemu
EA . .M- C.4 OUTLHT5
Policyp BUILDING DIVISI FRCS
Company G S- .SYS -OVER4(EA) PLANCHECK ITE
❑ Certified copy is hereby fumishcd.
❑ Cenitied copy is filed with the city inspection division. - GRFA TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEB
COMPENSATION INSURANCE
(Thissatiammandnm becompined ifthe permit is Income hundred do11urs($100) SEWER-SANITARY-STORM EA.20(Ff. ENERGY FRE
m less.)
I malty that in the performance of the work for which this permit is issued,l shall WATER DEATHS W/VENT/ELECI'R
not employ any person in any manner so as to became subject to the Workers' PAID
WATER SYSTEM/IREATING
Compensation Lnwa of California. Date WATER Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,Z g pion,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F` > bmhwithcame jm I.thecomply
Workers Compensation pnwitshall theeLabor Invked. ..at
> forthwith comply with such provisions mthie permit shall he deemed revnkeJ. BUILDING IL•E /a
Z CONSTRUCTION LENDING AGENCY SEISMIC IEE
1 hereby glicm that there is a construction lending agency for the performance of ELECTRIC FIiE
V O the work for which this permit is issued(Sm.3091,Civ.C.)
Lenders Name PLUMBING FEF.
Lender Address QTY. MECHANICAL PERMIT FEE
GUk) I ranify that 1 have read this application and warrant the above information is MECHANICAL FEE.. morn.lagn ato comply withacou
ll chyme! nty ed endinencesashite laws relating m PERMIT ISSUANCE
Vj bulldingcansmuction,and hereby authodrnpr
representatives up
tatives ofthiscry sumer on the
U ..an, .it property for inspection purposes. ALTER OR ADD TO ME CIL CONSTRUCTION TAX
We)n live,indemnify and kmp mandate the City of Cupertino again d
ir,' gments. is. •xprmaxi which tray many wayacerveagainsuaid City AIR HANDLING UNIT(TO 10."Cl
ons a ea th gr ti this permit. AIR HANDLING UNIT(OVER Ff"CFM)
Z n
nm of ApplicanVC vector Date EXHAUST FOOD(W/DUCT) PAID
IIA' RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,00)BTU) Dam Receipt
Willtheapplicant or future building mcupant score or handle mumoos mamrial HEATING UNIT(OVER 100,000 BTU) 1
m defined by the Copede,nino Municipal CoChapter 9.12,end the Heulth and Safety
Code,Station 25532(a)1
1:1 Ya 13 No .� VENTILATION PAN(SING LE RESID) \
BOILER-COMP(3HP OR I(lo,(X11)BTU) ISSUANCE DATE
Will the uvarbantnras asifilding by the Buy Are pmcrQuadi iceswhichemit p 1
heznrdnus air conmminamr as defined by the Buy Aree Air Qudiry Management BOILER-COMP(OVER 100,(X)B BTU) W
DistrictY
❑Yea ❑No NEW RESIDENTIAL.MECII. SQ.IT. FEBp
1 have reed the hasamous materiels requirements under Chapter 6.95 of the � a v71)
California Health&Safety Cafe.Sations 25505,25533 and 25534.1 understand that Lt�T♦♦���
it'dm building does not can
have a return,that it is my responsibility to notify the y� WI' lIu1�4.f1111`1
occupunt of the requirements which must be met prim maximum of a CeniBare of V I Y
Occupancy.
Owner or undulated spent - Data L: ISSIJF.D HY:
OFFICE-