27616 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDILDINc-ELECTRICAL PERMI'1'NO.
BUILDING DIVISION APPLICATION/PERMIT PL GPFTOJ CI]DENNI IC 27616
.i AUILDING PROJECT 1DEN'PIPICATION
BUILDING ADDRESS: l , SANITARY NO. APPLICATION SUBMITTAL DATE
is J UNIT Is LOTp 1^L
O ER N PHONE: CONTRACTOR'S NAME: LIC NO:
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733—%4/3
9 _ fWA!� �J '( N/C CONTROL#
111TECT/FNGINEE : =I�O: ADD RES0/R/ V1-itAOh �Y
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CONTACT: PHONE: u s P " "
I ' QTY. �+ ELECTRIC PERMIT. PEE � `BUILDING PERMIT INFO ,
E PLUMB MECH
PERMIT ISSUANCE'
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M9Z I hereby arfimvhaT l am lice... undmprovisions nfCM1apter9(commeneingwiTh JOB DESCRIPPION
[,10µ]0 Section 7000)of Division 3 ofthe Bisiressuan�dP f ode,and my license is In PANELS
aUE fall force and eHe— I�
aZm License Class Lic.# UP 70200 AMPS �� 1`�
ri LLon Date Convac 201-1000 AMPS {�t�/
Z FO Z ARCHITECTS DECLARATION OVER IOW AMPS SQ.Ff.FLOOR AREA S/SQ.IT.
O Z�O I understand my plans shell be used as public records.
I:,y�W SIGNS ELECTRICAL.
W�j Licensed Professional
6 OWNER-BUIIAERDECLARATION Cmdomme gPECIAL CIRCUIT/MISC.
cUc.. 1 hereby affirm that 1 am exempt from the Cono-mmr's License Law for The
W 3 a to following reason.(Section]031.5,Easiness and Professions Code:Any city or enemy TEMP.METER OR POLE INST.
which requires a permit to construct,alter,Improve,demolish,or repair any someone
>+� prior
rmimissaanccialsnrequnes the applicant fasueh permit to fileaslgnel,ca¢ment POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aldol+. 9(commencing with Serino7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iPoWCyy
.,That he is exempt herefrom and the basis for the alleged exemption.Any violeti.n.f OUTLETS SWITCHES-FIXTURES
ZaSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofLLIA CA!
Imorelhan five It dreJJollars(E500). NEW RESIDEN ALE CTR _SQ.PI'.
W m wlldothew�fresownerafthe property,.rmy employeeswith wagesustheirs.lecimpensation, STORIES YPt CONSTRUITION
R od,mad Theatmcwre is not imendeil.rofkredforsale(Sea 7044,Business
and Professions Code:The Corrector's License Law does not apply to an owner of
property whobuildsorimproves Thereon,andwhodoessuchavork himselftaflimigh his own
cmployeacprovided that suchimprovenscomare not]mmndeteroffrred reticule.If, OCC.GROUP RES.UNITS
however,the buildingor improvement issold within one year ofcnmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.), �( v "
Lllas ownerofthe properly,amexclusively contmetngwthloased communicate 11TY.t tea - �;PIAMDG
INPB LLyN " pBE PLOOD"LONB APN
consumer the project(Sec.7044,Bracrecs and Professions Code)The Cnnvncmxs PERMIT ISSUANCE
Licensel,awdues not apply to an ownerofpm,canywhn builds or improves Thereof,sal
wrecommns Bnsuchprojecls with ac.ntmetm(s)lieasedpumuant to the Contractor's ALTER W EA
License Law. 1 FEG SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this reusen BACK FLOW PROTECT.DEVIL OUTSID FES
SANITARY Y N
Owner Date RECEIPT#
❑RAINS-FLOOR,ROOP,AREA,COND.
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX Y
❑Workers
Co pensmthntlhrance oriifcateof copytherof(Sec.380,Lab C.)which
hich FIXTURES-PER TRAP RECEIPI'p
Workem'Compansmian Insurance orvecrtifiedwpy thereof(Sec.3800,Lab CJwhich PARR FRE YN
covers ell employee's under this permit. GAS.FA.SYSTEM-]INC. OUTLETS RECBIVJ#
Policy# BUILDINII)XVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ d entry is hereby famished.
Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thio section need not be complaW if lhepernit is for one hundmd dollars(§100) SEWER-SANITARY-STORM EA.20017. ENERGY
or less.)
I certify that in the perfarmancecfthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELECIR
not employ any person in any m as to become subject to the Workers PAID
ComPsamli.nl.aws.f Califio ia. Dates. WATER SYSTEM/TREATING DamRecein#
Q7+ Applicant
Z 0 NOTICE TO APPLICANT:If,after making this CenlBence of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fp. 'TOTAL:
rGI) became subject to the Workers Compensation provisions of the Labor Cade,you must
CCs'"' forthwith comply with such provisions or this permit shall be deemed revoked, BUILDING FEE
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE ��
Z Ihereby affirm That them is a construction lending agency for the performance of TOTAL: -ELECTRIC FEE
O the wad for which This permit is Nsued(Sec.3097,Civ.CJ
Lk. Lr Lenders Name 'y t i '' ' PLUMBING PEE
t-' Lader a Address QTY. $i f MECHANICAGPBRMIT h=I?BE'
U 317271
I certify that 1 have read this appllcatlmi and state that the vbase information s h' "- ' -
s�'s Lkl
correct.I agree to comply with all city and county ordinances and state laws relating In PERMIT ISSUANCE MECHANICAL FEE
buildingconsvuction,and hereby authorize representatives of this city center upon the CONSTRUCTION TAX
U Z above-mentioned property far inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless The City of Cupertino against
liabllhles,Judgments,vests a ad expenses which may in any way awmeagainst said City AIR HANDLING UNIT(TO 10,000 CPM)
1.consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) D
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CT)100,000 BTU) Rewipt#
Will The applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni Chapter 9.12,and the Hcelth sod Safety HEATING UNIT(OVER 100,000 BTU)
Cade,Section Vaa32(a)P e VENTILATION FAN(SINGLE.RESID) h
!!lICCCC DO]LER-COMP(311P OR 100,000 BTU) w � ISSUA TE
Will theapplieautor forum buil din eupam useegt ipmemrsde,icaswhichemi[
hazardous air rnnmmiaanls as d d by The Bay Area Air Quality Management BOILER-COME(OVER 100,000BTU, , "'PLANNER APPROVAL REQUIRED
❑Yes No NEW RESIDENTIAL MECH. SQ.FI'. PRIOR TO FINAL OCCUPANCY
I have reml the hazardous mmerials requiremets der Chepler 6.95 of theCGifmialiealth&SafelyCode, Gi +550 533 d25534. I understand that
7,Disfira?
f the ' mg nes sail at et it' y rradeaiofa To bine the
ant o uicimat. met r to issuance of a Cartifiate of -
/-//-9 S
a iso zt ed m Da¢ TOTAL: ISSUED BY,
OFFICE