27312APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERT INO InjimiING - ELhCTR CAI,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
n 7 Q aI n
G J 1 G
BUILDING ADDRESS:
LSO S��V21JSC��,K
UNIT# Lo LOT#
SANITARY NO,
APPLICATION SUBMITTAL DATE
l
OWNERaS DONE:
CONT QCT �N)p4E: C� C
(�O NS VL I �yy
L❑a
N/C
❑
CONTROLp
ARCHI'IECT/FSGINEER: LIC NO:
FJ
ISD e.S6
CONTACT: PHONE:
QTT ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
B ]IMIiCH
PIiRM11' ISSUANCE
SL1:1 15
LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm (hut 1 um liunsed undularavisione ofChupter 9 (commencing with
APPLIANCES .RESIDENTIAL.
TOB DESCRIPTION
PANELS
gec(ion9an" IfDivisionlof the Busines15 Professions Code�wd mylicense is in
full form loss "(rice
8 6 e
a
`.Y'\
i IJccnm Class Lich (0
UP TO 400 AMPS
7-
''�.
Date Common,
201 - 1000 AMPS
ARCHITECI"S DECLARATION
1 understood my plans shall he used as public retards.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. PT.
SIGNS ELECTRICAL,
Licensed Professional
OWNER-HUILDER DECLARATION
SPECIAL CIRCUH/MISC.
I hereby affirm that I am exempt from the Com(maors License Law for the
TUNP. METER OR POLE INST.
hollowing,coma. (Section 7031.5, Business and Professions Code Any citynr roomy
which "itires. pemtlt to cons(mct, after, improve. demolish, or repair any structure
poor to its issuance, also requires the applicant for such pvnnitto file a signed statement
POWER DEVICES
that he is hoonsed pursuant the provisions of the Contractor's License Law (Chapter
9(commencing with Section 7") of Division 3 of the Business and Professions Cade)
SWIMM ING POOL ELECT RIC
VALUATION
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant tea a civil penally of
TOUTLETS-SWITCIIL'S-FI%TURES
ant more than rive hammed dollars (550X1).
❑ I,asownerofibepropeny,ormyemployeeswi(hwagns theirsolecompiisation,
NBWRESIDINTIALELECTR_SQ. FT.
SrFORMS'TYPE
CONSTRUCTION
will do the work, and the structure is not intended nor offered for sale (Sm. 7014, Business
and Professions Code: The Contmcnrs License Law does not apply to an owner of
I
property who build,m improve iflo reon, end who dcossuch work himselfor through his
own employees,provilmlmatsuch improvements bromaintendMoroffered formle.It,
RES. UNITS
however, the building or improvement is sold within one year of completion, the owner.
hander will have (he burden of proving (hoc he did not build or improve for purpose of
,
QTY. PLUMBING PERMIT FEE
sale.).
❑ I,asownerof the property, atm exclusively contracting with licensed contractors to
FLOOD ZONE
APN
compact the pmject (Sm. 7044, Business and Professions Code) no Convector's
er,erry who builds or improves therm, and
License law does not apply to an owner ofpn
PERMIT ISSUANCE
who contracts mrsum projects with acnmtramor(s) licensed pursuant to the Cotnractor'n
License Law.
ALTER DRNN&VENT- AT (CAj
FETE SUMMARY
❑ 1 stn enempt under Scc. B & 1' C for this reason
BACK 11000 PRO'I'E L•VICE
01 T F. Flip
Owner Data—DRAINS
- FLOOR P, AREA, COND.
SANITARY YN
RECEIPT#
WORKMAN COMPENSATION DECLARATION
ElIhereby affirm that l have a mrdfi vn ofconmatto self-insum,orn comficate of
Workers' Compensation Insurance or o ceNfted copy therrof(See. 3800, 1o6 C.) which
SCHOOLTAX Y N
REC, M
FIXTURES- TRAP
PARK ME Y N
OAS -E YS .1 40UTLETS
covers all employee's undenhis per mit.
Policyp
REC3P1'M
BUILDING D ISIO EKS
PLANCHECK FEE
Company
❑ Cori copy is horeby famished.
G -EA. SYSTE 4n,Gnk
WASTE INT C. OR
is
GRADING FEG
Comfed copy is filed with the city inspection division.GREASFFJI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCH
GRWd
SOILS FEE
ANITAR TORM PA. 200FT,
ENERGY IEE
(TTis section need not be completed ifthe permit is for one hundred doll.($HKB-
or bees.)
WATE EATER W/VF.N'1'/ELECTR
I verily that in the Performance ofthe work for which this permit is iesuul,lsholl
not employ my person in any manner so us to become subject m the Worker%
PAID
Compensation Luwsof Culifontia. Date
Applicant
i,WATIIR SYSTENUTREATING
BrValRoccipt# '
NOTICE: TO API'LICANI:If, niter mxking tM1ie CeniOwtcof Cxcmptinn,yot should
become subject the Workers Compensation provisions of the Labor Cade, you must
N W RESIDENTIAL PLMB. SQ. FT.
TOTAL:
Forthwith comply with such provisions or this patent shall he deemed revoked.
BUILDING t. _
CONSTRUCTION LENDING AGENCY
SEISMIC F E
I hereby affirm that there is a construction lending agency for Ne performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
ELECTBI .FEE
Lmdera Address
QTY. MECHANICAL PERMIT FEE
PLI1M NG PEE
1 certify that I Lave read this application and state that to above information is
lagan to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MRCI I NICAL FEEcorrect.
building construction, and herebyauthariu repoesenutivesofthis city to moorupomhe
above-mentioned property for inspection phalanxes.
ALTER OR ADD 1'0 MECI I.
CONS UGTLON TAX
(We) agree to save, indemnify rind keep harmless the City of Cupertino against
Iiabilities,judgmems, costs and expenses which may in any way swerueagainst said City
AIR IIANDLING UNIT CPO 10,000 CFM)
in co enft ting of Nis pc,mit.
AIR HANDLING UNIT (OVER 10,0100 CFM)
4
ahyta Il�f! ppls m/Connacmr If
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT(TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle hazudous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100.(1(10 BTU)
Cale. Section 25532(a7^
El Yes El No
VENTILATION FAN (SINGLE RCSID)
Willeawhich
amminmofmurebuilding
aBayot equipment
BOILER - COMP QIP OR 100,1100 BI U)
ISSUIk[J�
•)M
DisYJW
es it by he
allous air camwninunts us defmcd by the Bay Area Air Quality Management
Quality Management
Districn
BOILER. COMP (OVER 100,010 BI UP
9w"
vY I`
El yes 0 N
1 have read the Incautious materials requirements under Chapter 6.95 of the
Sauey Code, li.must 25533 and 25534. I understand (het
ayd25534ibilirynramifythe
CCd...
IIthe
NIINv
fs uP VUrG
V11y
NEW RESIDENTIALMECH. SQ. FT.
thebuildingdosnotcurrently hoveo¢nam,theait is
o&
it[ or me,
amupum of the reyulmntents which must he met prior to issuance of to CeniEcam Of
ch
Occuryncy.
BY: lizz,10
Owner or awhrrixcJ agent - Data
TOTAL: ISSUED
OFFICE