27435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDICDINa-er.ECTRrczI PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECBANICAI, 27435
JBUILDING PROJECI'IDENI'HICAI]ON
BUILDI ADI E - SANITARY NO. APPLICAI'[ON SUBMI'YTAL DATE
UNIT# LOT# \
OW , NA E: PHONE: CO f CT R' NAME: �ly�Npsa�s„/
((�J•//'1//Y N/C CONTROLp
•ARCHITIiC'f. hIC ID Si ❑
CONT CT: Or PHONE: +' Y+p +'e-0
n Ur� ELECTRIC PERMIT- d FEq - BUILDING PERMIT INFO
QTY.'S
' w� s+ _*m'r_ �"'= � B D ELECT PLUMB MUCH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL III ��`
I hereM1 ffirm that l am licensed under TOB DESCRIPTION
pyZ yes provision ofCh.pmr9(commencing lice wit in
00 Seenioreand fDivisio Jof the Rosiness and Ds'o license is in PANELS
P;00
fullfmce and effe-� ! UPT0200AMPS
4'yz Liconsc C s C••! Lia#
h 6 y Dm Commctor 201-1000 AMPS
ZOvNaZ ARCHITECTS R OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
OZ—G and . wJ my plans shalleda puhlic tee ds.
pn W—J - SIGNS ELECTRICAL
9'4 Licensed Pnuessionnl
yy OWNER-BUILDER DEC RATION SPECIAL CIRCUIT/MISC.
OaU 1 hereby amrm that I am exempt found, Contractors License Lew home -
I_1 Ods followin,marmt.(Section]031.5,Business and Professions Code:Any city.,county TEMP.METER OR POLE INST.
F"�'ON 5 whichire
requs a permit to consumer,alter,improve,demolish,or repair any sanctum
M27 priorm is issuance,also requires the applicant forsuch permit to file.signed statement POWER DEVICES
F4<O that he is licensed pommumflo provisions of the Contractor's License Law(Quoter
w oPs 9(wmmcneiog with Section 700T.f Division 3 offm Business end Professimas Code) SWIMMING POOL ELECTRIC VALUATION
_w or than he is exempt herefrom and Ne basis for the alleged exemption.Any violation of OUTLETS-SWRCHES-FIXTURES
F_ZQ Section RIS LS by any applicant for a pnoinsubjects rhe applicant to a civil pcn.Oy of
¢ n mom than file hundred dollars(1500). NEW RLSIDENTIAL ELECTR S .FT.
C P-p n❑ 1,asownerofNepropcny.ormyemployeeswithwagesastheirsolecompensation, —SQ.FT TYPFCONSTRUCDON
p, m will do the work,and the structure is not intended coffered forsnle(Sec.]094,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
pmpeny who builds.,improves thereoo and who does such work hims,Um through Ns
cmployecs,provided that such impnwementsare not intendedoroffared fondle.If, OCC.GROUP RES.UNITS
however,the building.,improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sato.).
❑ I,mnwnerofthe pro en (nQTY. UAdBHJG PIiRMIT' iFEE FLOOD—ZONE APN
p y,nm exdusrvclyc.ntrammg wnhlcensedenmmetorsro l's _;
construct the projeet(Sec.](kq Business and Profession.Code:)The Contractors
License Law unearth apply to an ownerofpropenywho builds orimpowesthere.n,and PERMIT ISSUANCE
who contracts fmsuch projects with a contractors)licensed pursuant to the Conuactors AUGER (EA) o.
License Low. ILC SUMMARY
❑ I um escmpt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE UTSIDE I:h.
SANITARY Y—N
—
Dole Dam DRAINS-FLOOR,ROOFRECF.IPI'p
WORKMAN COMPENSATION DECLARATION . .A.GOND. SCHOOLTAX Y_N
❑ Thereby af0rm th.tlhuveecertificme of consennn selLinsuro,oracmif¢me of FIXTURES-PCR P RECEIPI'p
Worked Compensation lnsunmce ora certified copy thereof(Sce.3800,Loh C.)which PARK FEE Y—N
—
covers nil employee's urdenhis permit GAS . STEM-I INC.4 OUTLETS � RECEIPT If
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4 EAQ PLANCIIECK FF.E
❑ Certifedcopyisherebyfumiehed.
❑ Certified copy is fled with the city inspection division, GREASH/INDUSTRL WASTE I RCEPT'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PEE
COMPENSATION INSURANCE
(This section need not becomplemdif thepcmdn is forone hundred dol (1100) SEWER-SANT R S' RM EA.2M ENERGY ME
.,less.)
I cenify that in the performance of the work for which this Permit is issue ,I shall WATE IP W/VF
not employ any person in any manner so as to become subject to the eskers' PAID
Cmrswmationfawsof Calirmmia. Dam A SYS BBA' Date Receipt
OZ Applicant
O NOTICETO APPLICANT:If,after making this Certificate of Exem ton.you a uld N WRESIDE PLMH. SQ.FT.
Z 8 r i TOT L:
F" become suM1jectmthe Workers Compensation provisions of the Labor Code you ust
a '�^ forthwith comply with such provisions or this permit shall he deemed revoked. BUILDINGFEE r�
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z. 1 hereby affirm first them is a construction lending agency for the performance f
U O the work for which phis permit is issoed(Sm.709],Civ.C.) TOTAL: ELECTRIC FEC
Lender s Name d
W- P Lenders Address =MIiC1fANICAL PERMIT FI?li PLUMBING FEh
U I semfy Ih have read this.,]Icahn.and state that the above mf.nn a on is ' '
torted. lag, to reply withal)city and county ordinances and state laws miming to PERMIT ISSUANCE MECHANICAL FEF,
F-' y buildings state n,and herebyauthorice representatives ofthis city answer upon the CONSTRUCTIONTAX
U 7 above tin prvpc spectim puryous. ALTER OR AILD TO MECH.
•7 ej rce to r e,in r nify and keep h.mdns the City of Cupeninn.,.fast
,jaJgmcn ndexpwsee which may In any wuy.cvTuea.lost sniJCiry AIR HANDLING UNIT(TO 10,0010 CFM)
or
of .coring of phis qumin. /
AIR HANDLING UNIT OVER IgIXp CFM)
Jigrtt( A 'ommn.r ate EXHAUST HOLD(W/DUCn
PAID
IIAZARDOUSh TH IALSDISCLOSURE I IEATINGUNIT(TO100,00013TU) Date Receipt At
W I the applicant or future buil in ecuparr slum or handle hmardous material HGTING UNIT(OVER IW,IXq BTU) T
as def ed by the Cupertino Municip rue,Chapter 9.12,and the Health and Safety
Code.Semion❑255 2(a)] 13 No VENTILATION I-AN(SINGLE RESID) g
Wit area (cant or future building occupant BOILER-COMP(3HP OR I NOW BT U) ISSUANCE DATE
pp goccupnn equipment which emit
hazardous air comamimenrs m defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District] ❑ P A
Yes ❑No NEW RESIDENTIAL MECH. SQ,IT.
1 have rend the Imaanlons materials requirements under Chapter fi.95 of the ��� 13 ����
California I lenith&Safety Axle,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have u tenant,that it is my responsibility to notify the
occupant of the requirements which must M met prior to issuance of a Cmificate of
Occupancy,
CfIY ser 1 iI
Owner or umhorimd agent Date '1'O TAI.: ISSUED BY:
OFFIC