27574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC OICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 7 5 7 4
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION
BUILDING AUURESS: SANITARY NO. APPLICATIONSUBMTITALDATE
2 VI �V UNIT# LOTH �2— Al
NIiNS NAME Ou� I HONE:
✓(e-- JI C xRiCfOR'S NryIE: LIC NO:1 MC l CONTR'•O'L N-- ,•
V�
ARHITEC 'ENGINEER: LIC NO: DRESS ❑
CONTACT: PHONE: 1.
QTY. ELECTRIC PERMIT BUILDING PERMIT INFO
F[EE
/ BL ELECT PLUMB MECH
/►7 /T h PERMIT ISSUANCE 0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pp2 Thereby ofrmmatl end 3 ofth Business
od nder ssand isiomoons Code 9nd(commencing with
1sJ02t of❑ $¢tion e and e f Division J of the Bmineac and Professions Code,end my license is in PANELS
y V U full forty and effect.
LQ.,Z In License Class Lic.# UP TO 200 AMPS
m<y Date Convector 201-1000 AMPS
ZONZ ARCH][[CTS DECLARA'TICK OVER Ip1UAMP5 SQ.171.FLOOR AREA $/SQ.Fr.
O'L—O I understand my plans shall be used s public records.
F=.la F w SIGNS ELECTRICAL
Q��,',j Licensed Pro(casinnul
Eyd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUTHMISC.
KOi� 1 hereby affirm that 1 an exempt from me Contractors License Law for the
'iZl, following reamn.(Section]031.5,Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST.
F`-mJ which requires a permit to construct,alter.improve.demolish,or repair any nhmcture
522 7 prior to its issuance,also requires Neapplicaat for such permit to flea signedstate in POWER DEVICES
"<0e that he is licensed pnsured to the provisions of the Common'sLicrnx Lvw(C pier
a KOo la. 9(commencing with Section 7")of Division 3 afthe Business and Profession 14,1tIMMING POOL ELECTRIC VALUATION
WMoo or that he i.exempt herefrom said the basis for the aleged exemgion.Anyvi anon of
F_Za Section 703 IS by any applicant for n permit subjects the applicant civil natty of OUT S-SWITCHES-FIXTURES
s mol more than It hundred dollars($500).
�Fo ❑ Lasownerofthe norm Io res wimwe esasthcirsolee NEW RESID ALELECfR _SQ.Fr.
#rape y ycmp y g nperlammn, STORIES TYPECONS'IRUCHON
x322 will do the work,and the structure isnot intended mothered fnrsale(Sec. ,Businessse
and profevsions Cnle:'ITe Qm[raaor's Licence Law mcs not apply criticism,or
property who builds orimproves thereon.and who does such workhi Ifarlhroughhis
on employees,providelthat such impmm
veeme ad
ntsnot inteedu fferedforsale.IL OCC.GROUT' RES.UNITS
however,the building or improvement is sold within one yearofc pletinn.theewnef- 'TOTAL:
builder will have the burden of proving mat he did not build or' prove for purpose of
sale.).
❑ 1,asownerofthepmNny,amexclueivelycontmetin ithlionovdcomtrscmr.m YNG Pr/MIT FEE FLOOD ZONE #pry
construct the project(Sec.7044,Business and Profs.- as Code:)The Contractor's
License Lawdoes not apply tossummerefpruNdyw oil&or improves themon.and PERMI'(IS$ NCE
who contracts for such projects with acontmemr(s)I'ensedpursuanuothe Contrectol A .ER IN&VEN -WATER EA
LicenseLaw. ( ) FHESUMMARY
❑ 1 em exempt under Su. ,B&P C for this BAC OW PROTE .DEVICE Wpm�FEF,S
Owner Dam n SANITARY Y N
• AINS-FLOOR, OF.AREA,COND. RECIBPT#
WORKMAN COMPENSA ON DECLARATION SCHOOL TAX Y_N
❑ Thereby affirm NalhaveacMifcate of umt0 sel"remre,or e¢ f Xl'URES-PER AP RECF.IPTp
Workers Compensation lamostermaeerifedeo beteaf(Sec.3800,Lab C.) ih PARK FEE Y_N
covers all employee's under this permit. GAS-EA.SYS MAINC.40UTLE'TS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SY EM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumixhed.
❑ CenifN copy is filed with me city irlspeniondivisioa GRFASFIIN USTRL WAS TE INTERCEPTOR GRADING FGIi
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS RAP SOUL FEE
COMPENSATION INSURANCE
(This section need not be completed tribe permit is for one hundred dollars($100h SEWER-SANITARY-STORM IDS.20117.
less.) ENERGY FEE
ar
Iemify that in the Niformanceofm<work for which this permit is i.sued,l shall WATER HEATER W/VFNr/ELECIR
of employ any person in any manner so as,to become subject to the Workers PAID
Z Compemitunr Lsoc—f Califomia. Dote WATER SYSTENITREA7'1NG U#le Recc' N
Applicant
2 O NOTICE TO APPLICANT:IL after making this Cenifcare of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTA1;
. 4 become subject lathe Workers Compensation Provisions ofthe Labor Code, no..it
C4 7 rorhwith comply with such provisions or this permit that l be deemed revoked. BUILDING
D CONSTR UC ION LENDING AGENCY SEISMIC
z I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.300,Civ.CJ TOTAL: ELEC E
1<ndces Name
0 U Lender.Address QTY. MECHANICAL PERMIT FEE PLUM G EE
1 certify that 1 have tend this application and slate that me above information is I
CW. correct I agree to comply with all city and county ooiinances and state laws.elatingto PERMITISSUANCE MECHANICAL
F-' h building corLcmction.and hereby au amoe representatives oflhis city to enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIO TAX
(We)ogre m save,indemnify and kap beradess me City of Cupertino against
liahilities.judgmcnhs,costsand expenses hichmayinanyway an rue again.u:id City AIR IIANDLING UNIT(TO 10,0g1 CFM)
encc ofthe granting of[his it
AIR HANDLING UNIT(OVER 10,1300 CFM)
nutute olAppliam/Contract.! Date EXHAUST HOOD(W/UUCT)
PAID
HAZARDOUS MATERIALS
rt11DISCLOSURE HEATING UNIT TO IW,IXq BTU) Date Be,
Will the the Cupertino
ar furore building occupant store or handle Health a material
as defined by the Capcnino Municipal Code,Chapter 9.12.ertd the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT
CMa Station 25532(n)T
❑Ycs ❑No VENTILATION NAN(SINGLE RBSID)
Will meapplicantorfmurebuildingoccupanmxequipmenmrdeviaBOILER-COMP(3HPORIpg01t BTU) ISSU C ATEswM1ich emit
hmardous air comaminants as defined by the Buy Aren By Air Quality Management BOILER 10),WO BTU) V_
Di,aricR tf/�
I
J El No NEW RESIDENTIAL MECH. SQ.Fr. DEC 2Z 19
have read the haznrduus matenuls requiremems under Chapter 6.95 of the
ealth&Safery Codc.Sections 25505.25533 and 25534.1 aoderslartdmmg Jcesnm currcndy haveamnant.that it ismy responsibility[o nmify theCITY Ur lUh'tHIthe rcyuiioisucelhonzed a gent Dule TOTAL: ISSUED BY: i
OFFICE