27615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUH.DIN'r.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAL 27615 1 C
BUILDING PRf IJECI'IDENTIFTCAT'ION / 1J
BUII ADDRESS; /'Jf/'�''� SANITARY NO. APPLICATION SURMUTAAL DATE
f�A1N 6at.
� ]XIV4a_ UNIT'# LOT#
Z(I NER NAME. PHONE: C N'I'RACTOR'S NAME: LIC NO: J
ANDmha,k- 9 ///19�f N/C CONI'RlL#
(ITEC IFNGINE717R: LIC O: ADDRESS: �/0�.7
11C L �16uI G /O 4Trp >�1 �w6 /5�
CONTACT: PHONE: Ta§', +(g' J t > `,;BUILDING PERMIT INhO
TY. y�g ELECTRIC PERMIT. FEF.
+�'rsdr&Z 733-90-,7 �A9 PERMIT
SUANCItti'ccBLDG EI.LCI' PLUMB MliCll
PP.RMIT ISSUANCE Qs ,fes
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTW.
OCZ I hereby affirm that l am licenudunderprovisionam'Chapter9(commenemgwith JOB DESCRIPTION
ts100 Section 7000).(Division 3ofahe Businesstud Professions Code,and any license is in PANELS
K d t full force and effect.
Fyly License CE s Lic.# UP TO 200 AMPS
yQy Dale Conrracmr 201-IOOOAMPS
��N7� ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.FT.FLOOR AREA $/SQ.IT.
OZ.,O IunderstandmyplaresM1allbeuseAaspublicrecoNs. /✓� S
(..y F W
SIGNS ELECTRICAL
Qy l� Licenxd Professional
Cd, OWNER-BUILDER DECLARATION SPECIAL CDtCUIT/MISC. /
WLF 1 hereby affirm that 1 am eaempr from the Conarectm's License Lew for she
W?OmG following reason.(Section 703 3.5,Business and Professions Code:Any city or county 'TEMP.METER OR POLE INST. O
2. J which acquires a)omit to outsmart,eller,improve,demolish,or repair any stmmure
prior to its u.mmogatm tortures Ne applioonl far such permit file aligned statement POWER DEVICES
GO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
L rG 9(commencin with Section 71100)of Division 3 of the Business end Professions Code SWIMMING POOL ELEMIC
oro la, (commencing ) VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F Z.Q Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of OUTLETS-SWITCHES-FIXTURES
S O amore Nan five hundred dollars($500). NEW RESIDENTIAL ELECIR 5 .Ff.
Lesownemftheproperty,ormyemploymswirh wagesastbeirsolecomper atiom, Q STORIES TYPE CONSTRUCTION
m �
y _ will do he work,and the spicame isnot initiated oroffered forsale(Sec.70,14,Business
and Professions Cole:The Corrosions License Law does not apply In an owner of
property whohuildsorimpmves thereon,end whodues such workhimselforthssugh his
own employees,provided that such improvements are not intended mufferul forsale.If, OCC.GROUT' RIN.UNU'S
however,rhe building or improvement is sold within one yearn(completion,the owner- OTAL.
builder will have the burden of proving that he did not build or improve for purpose,of
sale).
❑ I,asowmTofrhepmNny,emexclusivelycontmctingwiNlicensW n=tomm QTY'., -" PLUMBING PE FEE FLOODZONE APN
construct the projert(Sec.70abq Business and Professions('ode:)The Comumusex
License Law does not apply man ownerofpmpeny whobuildscrimpmvealhereon,and PERMIT ISSUANCE
who contracts forsuch projects with acomrarsona,licensed pursuant m the Commcmrs ACPGR.ORAIN&VHN'f-WAT[R
I.,mr,v Law. (EA) - FEB SUMMARY
❑ I am exempt under Sec. B&P C for this mason BACK FLOW PROTECT,DEVICE 0 SID ES
SANITARY Y N
Owner DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT If
WORKMANCOMPM- TION DECLARATION SCHOOLTAX Y N
❑ Iherehyalivtilus have a marificomofcomumitoself-insum,oracenifice¢of ' LIPI'p
Workers'Compensation lnsurancem.renified copy,thereof(Sex.3900,Lab C.)which IBXTURES-PER TRAP PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM.I INC.4 OUTLETS R CEIPT#
I'ulicy# HI➢, i IJIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is riledherew th dforre ed.
�]/[brtified copy is fled with fiecity inspersion division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASGTRAP SOILS HE
INSURANCE
(This action need nm be completed ifihe permit is for ane hundred dollars($100) SEWER-SANITARY-STORM EA.201 RNFRGYFEE
or less.)
I certify that in the performance oft he work far which,hia permit is issued.I shall WATER HEATER W/VENT/HLECTR
not employ any person in any...or so as as lecome subject to the Workers' PAID
Compensation Lawsof Celifomia. Date WATER SYSTEMTREATING Date Receipt#
Z Applicant
Z C NOTICE TO APPLICANT:If.after making this Cenifinm of Exemption.you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
rrte-, bmomcsabjecr to the Wmkers Compensation provisions of the Labor Code,you most
> forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE 0-0`
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affmn that there is a construction lending agency for the of TOTAL GLECTRIC FEE
O the work for which this permit is issued(Sm.3097,Civ.CJ
4Ls Ir lander'.Name � I., r t
.0 [.enders Address QTY. ' MECHANICAL PERMIT -FF.E PLUMBING FEE
U I modify anal 1 have mad this application end state that the above information]s }^ -
>" Ida correct.E arm to comply withal]city end countymiinances andsrare laws relating m P[RMITISSUANCE MECHANICAL FEE Ut
building construction.and hereby authorise oe xomamives of Nis city to enter upon the CONSTRUCTION TAX
Z above mentioned property for inspection purposes. ALTER OR ADD TO MEC$I.
(We)ogre¢ ,,save,Indemnify and koap harmless the City of Cupertino b.hat
liabilities,judgments,casts and expenses which may in any way accrueagainst said City AIR HANDLING UNIT(TO WBW CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applican4Comncmr Dote EXHAUST HOOD(W/DUCT)
PAID
IIAZARDOUSMATF,RIALSD[SCLOSURE HEATING UNIT(T0100,0fID BTU) Dam P X*ija
Will the applicant or fmure building nccurymr store or handle homrdous material I(RATING UNIT(OVER 100,000 BTU) TOTAL:
its defined by the Cupertino ManicJ'gal Code,Chaplet 9.12,and the Health and Safety
Code,Section 25532(a)7 .
❑Yes ifj•( VENTILATION PAN(SING LE RFSID)
S UANCE
Will thea licancorfmurebuildin occu amuue BOILER-COMP(JHPON IW,1ggBTU) C117 ser
PP g p 9eaAirtQalityMangement HIIN
Nori ous ser canmminonta as reed by the Boy Arca Air Quality Management BOILER-COMP(OVER 100,000BTU) L•U�t (J
Divrrict7
❑Yes No NEW RESIDENI'IAI,MECH. SQ.ITT. n--I l
ANNER AIREQUIRED
1 have mad the hazuMous materials requirements under Chapter 6.95 of the
California Ifi alah&Safety Cade,Sections 25505,2553)94d 25534. I understand that RIO-1 7! a ?ANCY
lith�bu! d�, rem] nt, itis responsibility mnotify thearssu a ofa Cerificme ofmc
t g t Date TOTAL: ISSUED BY:
OFFICE