27482 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ISHII.DING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMUING-MECHANICAL 7 ^ p
BUILDING DIVISION BUILDING PROJECT'IDEN'T'IFICATION 4 O
BUILDING ADDRESS: SANITARY NO. "MICA TION SUBMITTAL DATE
O 22 UNITN LOTp /—L9 —I'l
OWNT: NAME: PHONE: CO R'S NA S , LIC
_ .'IJ NIC CONTRO A
® A 111 CT/ENGINEER: I LIC NO: A R'SS ❑
CONTACT: puDNE: QTY. ELECTRIC PERMIT FEE DOILDING PERMIT INFO
BLDG ELECT PLUMB ECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm that l am licensed under provisionsofChvper 9(commencingwith
WOO Section 7")of DivisionSof Ne Business and Professions Cade.and my license is in PANELS
<. Liemsefull f Clasand<ffr�r{ ry/_ UP AMPS
,ZW Licenic Clasx_1 -!7((�LiaN 1 '
rn,GN Data ontmeor 201-I"AMPS
Z FOv'Z. S LA N OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.Fr.
OZ—= lundcmand as To event
r -SIGNS ELECTRICAL
2y$� License sio
�y W Q -BUILDER DECLARATION SPECIAL CIRCUITIMISC.
iaC O W U 1 ereb aft that am exempt from the Conlractor's License Law for the
n13 a y following a...n ecf 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F LL O which m utrcx a it to commis,.lief,improve,demolish,or repair any suucture
yr�Q2 prior m its issuance,also napalm the applicant for such pennifto rile a signed statement POWER DEVICES
IyC<O that he is licensed..rsuanmo the provisions of the Contactnr's License Low(Chapter 660= 1)(commencing with Section 7000)of Division 3 ofthe Business and Professions CW,) SWIMMING POOL ELECTRIC VALUATION
Wroy or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OIITLEfS-SWITCHES-FlK'NRFS
FZQ Section 7031.5 by any applicant for a Parnal subjects the applicanuo a civil penally of
fS0 notmme than five hundred dollars(5500). NEW RESIDENTIAL ELECI'It _SQ.FT.
C3 1.asowncroftM1epmpenY•ormycmpbyces with wagesuatheirsolecompensntion, STORIES; TYPECONSTRUCTION
y3°p willdo the work,and the suucmre isnot intended mothered for We(Sm.7044,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
property vehobuildsorimprnse,thcmon,and whodoessoch work himselfof through his
own employees,provided that such improvementsam not imumdedofofferedforselle.If, OCC.GROUP RIS.UNITS
however.Ne building or improvement is sold within ons,yearofcomplebon,the ve rovi
owner- TOTAL:
builder will hanhc burden of png nkat he did not build or improve for propose of
TOTAL-
sale.).
❑ Lasowner()fine property,an enclusivelyconuacting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors
License law doesnm apply manowneroPou,city whabuilds or impmvesimmo.and PERMIT ISSUANCE
who contracts brsuch projects with axrntractor(s)licensed pursuant to the Comrnmors
License Law, ALTER WATER(E )
FEE SUMMARY
❑ I am a maria under Sec. ,B&P C fur this reason BACK FLOW PROTECT.DF.VICF. SIDE IV ES
SANITARY Y—N
—
WORKMAN
DRAINS-FLOOR.ROOF.AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION
ION
❑ SCHOOL TAX Y N
Thereby ef0rm thmihevea«ni0cate of commmxlf-i mure,milrenlficamcs' FIXTURES-PER TRAP RECEIVF#
Workers'Compemame
acion lnsumem a unified copy lhersef(Sec.3800.Lab C.)which PARK FEE Y N
calms all morel nyw�s�rylyOryi. pt((!/ GAS INC. 0UTLETS RECEIPT'.
Compare n4l( ,ohl6" BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 TEA)
❑ Certified copy is her r���J PLANCHECK FEE
IT,P�(Cenifed copy is filed with chiccity inspection division. GREASUn NDUST W T INT R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' f GREASIGTRAP
COMPENSATION INSURANCE I w �� I SOILS FEE
(This section remain he completed ifthe permit is for one hundred dollursfSllxp SEWER-SAtT11YA - TO M T- ENERGY HE
or less.)
I certify that in the performance of the work for which this permit is issued,l sha111 WATER HEA W
not employ any person in any manner so as to become subject to the Worker' r PAID
Applicant
Z-. Gsmpensation Laws of Califomlo. Dote W TER SYS T Dole Receipt#
0 C) NOTICE TO APPLICANT:If,after making this Certificate.(Exemption.you Jalrlld NEW RESIDENTIAL PLMB. SQ.IT TOTAL:
Fr4 become subject In the Worker's Compensation provisions of the Labor Code,you must
7 fonhw ith comply with such previsions or this.emit shall he Jcemed revoked. BUILDING FEE
1 O CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of
U O the walk for which this.corm i is issued(Sec.3097,Civ.C.) 'f01'AL: (Jp ELECTRIC FEF,
Lmdm's Name
QU Lender's Addmsa QTY. MECHANICAL PERMIT FEE PLUMBING FEE (�
r 4t1 I verify that 1 have mad this application and state that be above information is
F0. svnrcct. lagrcc In comply with all city iced county oNinancex and scam lows relatingnr PERMIT ISSUANCE. MECHANICAL FEE
-' fA building construction,and hereby authorise repreunwtivesef this city to enter upon the
U Z above-martiomcd propcny for i ,an pu ALTERORADDTOMECIL CONSTRUCTION TAX
(We)agree m as try mp h $a the City of Cupertino aga'nn
h.hilitics.ujudgnea ,which oyiminywayamr.m.,aimts' City AIR HANDLING UNIT(TO 10,"CFM)
in corse me a ear this pe
AIR HANDLING UNIT(OVER 10.000 CFM)
Si or I nnnmor e EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOS E HEATING UNIT(TO 100,000 BTU) Due Receipt as
Will pplieant or furore building occopam scene or andleM1vardous material
define y the Cupeninn Municipal Axle.Chnpmr 9.12,and ilia HenhM1 send Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cole,Section 25532(a)?
❑Yes No VENTILATION FAN(SINGLE RFSID)
BOILER-COMP LA IP OR 100,(100 BTU) ISSUANCE DATE
Will Iain cmiconmras as bulldingrccu a Bay Am.Air .alit tee which emit p
'hazardous air comaminanu as defined by the Bay Area Air Quality Management BOILER 100.000B P % '
Distrix? BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
L read the hurardous materials rcpuiremcros under Chapter 6.95 of the J[�AP Q
ealth&Safety Code.Sections 25505,25533 and 25534.1undersandthat �1IItl fir/
g does not currently have a tenant that it is my resgmsibility to notify the ) v"
the rcpoiremcmts which onto be met prir to issuance ofa Cenificam of iIy/Uf LUI.
/No
m sed agent Date
TOTAL: ISSUED BY:
OFFICE