27036 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD] G-ELFCPRICAL PERMIT NO. 27036�O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISIONBUILDING PROJECT'IDENTIFICATION
BUILDING wDU IES$!1 p . SANITARY NO. APPLICATION SUNMITJpL DATE
8 \U�'h tVaVytl 1pN^k Y/TVLI UNITS LOT'S /sal
OW E SNAME: /n i� Pf_RM CONTR JVfNAME: I LIC# N/C CONTROLS
ARCI HECT/ENGINEER: LIC NO: ADDR tll- ❑
COSTA PHONE QTY.
(/� QTy ✓✓✓ ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I- f �S//" PERMIT ISSUANCE BLDG ELECT PLUMB MEC
v ❑ ❑
LICEEU CON'I'RAM'ORS DECLARATION APPLIANCES-RESIDENTIAL
pyZ I hereby affrmthat l am licensed underpmvisionsof LTapter9(commencingwith ,UGC ESCRIPfI
�00 Section 7kXL of n Jof the Buairecto COJ ,license is in PANELSl�
E m
aUU full torte soda ' yin so
f�n¢
HZW License Class Lic.p YiI//W� UP T02lq AMPg
m=y Date Cmuracmf 201-1000 AMPS
ARCHITECTS UF,CL I OVER IIXNIAMYS SQ.FT.FLOOR AREA S/SQ.Ff.
OZ-0 1 understand my plans shall M used ow public mot
F w F J SIGNS ELECTRICAL
Hoc: Licensed ltnfessionel OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC. W
Hoc:a V I hereby affirm
That T am exempt from the Contmeme,License Law for the
1+13 ah following reamn,(Section 7031.5,Businecs and Professions Cade:Any city me.cray TEMP.METER OR POLE INST.
L' J which moieties a permit 10 onsom 1.allec improve,demolish,or repair any structure,
toi¢issuance,alsoreyui...thcapplicamforsoch petmino file.signed smmment POWER DEVICES
Tal pz that he is licensed pursuant o the provisions of The Contractor's License law(Chapter
6KOLL 9(commencing with Section 7000)of Division Sof the Bionnew and PoOfessions Code) SWIMMING POOL ELECTRIC VALUATION
W or he is exemptNcrcl'mm and the basis for alleged exemption.Any violation of LETS-SWITCHE9-
FZ� Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of FIXTURES
not more than five hundred dollars(5500).
�F� ❑ I,mownerofthe Vopny,ormyemployeeswiNwagowt irk ompensa4on,-s \ WRFSIDENTIAL FIECR3 _SQ.FT. STORIES TYPE CONSTRUCTION
d3- will dothe
sim,ands strucmmisnot intendedLimeme offc f sat ( c.
and property
wh ons ldveri pr Conmecmr's License Lewd n t to owner
prop employces.prsorimproveschimp and emanod«ssuch o elf
is
own cmr.the bs,pnnori improvement
ntsercn Ie c offc of to le.If,wne, OCC.GROUP RE.S.DNIT$
however.have l the burden
ofpmving t crow a ofc o for owner-
builder willhavetheburdcno!proving th h n o� uild nr btr purpose of TOTAL:
sole.), ro
❑ Leanwnerofihepropeny,amexcluste ys atmaingwiNl nacdconerenorsm QTY' PLUMBING PERMIT FEE IT ODDZONE APN
melrun the IoNst(Scc.70W.Business a it rofessions Code:)The Conti mdc
License Lawdoesnotepplymanownerofpm whobuitchmimpmvcslhereoo,and PERMUF ISSUANCE
wbocomraas for such projects with aramracrogs)licensed purxuanuolhe Conlmmnr's ALTER License Law. DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l ern exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OUT FEES
Owner Data SANITARY YN
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
1 hereby WORKMAN COMPENSATIONofcxmx ECLARATION SCHOOLTAX Y_N
Wo em'Conaffrminlesurachat I have a certic ode.,,,hcmwfhSoc.3e.oracb CJwteof MIXTURES-PER TRAP RECEIPT#
Workers Compensation lnaurantt oracey��dcopy Nereof(Sec.JgoO,Lab CJ which PgRK FEE yN_
Policy#oveirsoiIl cmpl c 1 if�elBit,CO 1 GAS-EA.SYSTEM-I INC.40UTLEIS RECEIPT#
V�!/ Jl/ BUILDING DIVISION FEES
Company GAS-EA.gYSTEM-OVER4 FA
❑ tified copy is hereb ( l PLANCHECK FEE
Certified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS PEE
COMPENSATION INSURANCE
(This section aced not be completed ifthe permit is for one hundmddollars(SIM) SEWER-SANITARY-STORM EA.200IT.
or less.) ENERGY FEE
I certify that in the performance ofthe work for which this Permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner as to become subject to the Workers' PAID
z Con,sensmlon Lawsnf Callfomia, Dam so WATER SYSTEM?REATING Dom RaeiptN
Applicant
'ZQ NOTICE TO APPLICANT:If,afmr making this Cerilicam of Exemption,you should NEW RESIDENTIAL PLUS. SQ,FT. TOTAL:
Fy become subject to the Workers Compensation previsions of the Labor Code.you must
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
y CONSTRUCTION LENDING AGENCY SEISMIC FEE
a 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.3097.Civ.C.) TOTAL: ELECTRIC FEE
IL bender's Name
O U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FRE
I terrify that I have mail his application and seta that The above information is
H6Wi correct. l agree to comply with all city and county ordinances and one laws mlating to PERMIT ISSUANCE ^ MECHANICAL FEE
rn building construction.and hereby normal representatives ofthis city toenter upon The
U aawt-o imenedpropenyfor inspechionpurpnses. ALTF,RORADDTOMECIL CONST'RUCIONTAX
I ).gree to save,indemnify and keep harmless IM City of Capes..against
liabilit j green¢,costs and expenses which may in any way accrue.gainstsaid City A IR HANDLING UNIT(TO 104000 CFM)
ircue of the granting of This pemtit.
" AIR HANDLING UNIT(OVER 10,0)0 CFM)
Sig fApplicanVCommcros Data EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Receipt p
Will the applicant or future building occupant store or handle hvardMOO
rial
as Aefincd by the Cupertino Municipal Code,Chapter 9.12,and the Health Safety HEATING UNI'I'(OVER 100.000 BTU) ( w .
Cade.Section 25532pyf
❑Yes Cl No VENTILATION PAN(SINGLE RESID)
Will Nee applicant or fummbuildingoccu antesBOILER-COMP(JUP OR IfI0,fKK1 BTU ISSUANCE DApP p cquipmenmrdevicesit ) Bh mduue air emem nam,as defined by the Bay Arca Air Quality Mnt BOILER-COME(OVER 100,000 BTU)Dis nY
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FC A /G ,07L'—'--"�up,- �rtad Ih<hammous materials rv{uircmems under Chapter c UG `e "&. fetyCode.9ections 25505,2553)and 255M. lundat /a s curn0ynaveaconcetNet it is my responsibi y te CII Yc oi ems w ten n I be m poor m mospoc racUf t IT aqV
nod dagem
TOTAL: ISSUEDB .
OFFICE