27955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION - PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CHANICAI.
BUILDING PROJECT IDRN'TIFICATION 27955
BUILDING ADDRESS.
- SANITARYNO. AP K/ATIO�N S//UrrB��MfITAL DATE
/a��" '_ d �4 UNIT# LOT
OWNERS N/AyE: pPH NE:- CONTRACTOR'S NAME
: LIC NO: /
LT / a /Q N/C CONTROL p
RCHITF.CT/ENGINEER: LIC NO: ADDRESS: �• ! ❑
CONTACT: O t A�U PHONE: Ave. S9 4 y
0 J, S/7/j QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT U EC
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S'SDECLARATION APPLIANCES-RESIDENTIAL
�i100O00 Thereby nffDM,,non that l amlicensed inss add rifesions Code.a(co mmencing with � JOB DESCR ION
3emian]OW)of Division3 mum Business antl Professions Code,and my license is in PANELS
azw fullforceande�,/ q
yG4 Dctense Claxs ` O Liak ✓ UP T0200 AMPS
I"'y Z ARCHITECTS DECLARATI N Contractor 201-1000 AMPS
ZOvr— Iunderstandm I Pu OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ{{—�..0 my shell be usedaz blit records.
�.N. ; SIGNS ELECTRICAL
Lmensed Pmfessron.l
OWNER-BUILDER the Co DECLARATION SPECIAL CIRCUIT/MISC.
3 Odf 1 hereby affirm that I mn exempt from the Contractor's License Lew for the
w fol lowing reason.(Section 7031.5,Business and professions Code:Any city presently TEMP.METER OR POLE FIST.
y; which requires.Facto to construct,alter,improve,demolish,or repair any stramure
°aa pnortoits issuance,alsorequires the applicant far such pemdt to file.signeeNstateradern POWER DEVICES
rl p p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
WM, or that he is exempuhomfrom and the basis for the.11eged exemption.Any violation of
F G
Section 7031,5 by any applicant far a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FLXTURES
O not marc than five hundred dollars($500).
yK ❑ Lasownerofthepmperty,ormyemployeeswithwagesstheirsolecompmation, NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
willdmhework,end the stmnureisnot intended orofferetl forsele(SecJ044,Business
and Professions Code:The Commences License Law does not apply he an owner of
Property who builds or improves thereon,and who does such work himselfor through his
ownemployees,provided that such improvememsare notintendedormhadd forsale.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ 1,asownerofthepraperty,vnexclusivelyconoactingwithlicensedcontracmrsto QTY' PLUMBING PERMIT FEE FLOOD ZONE ppN.
construct the project(Sec.]BMT,Business and Professions Code:)The Comment,
License Law does not apply to an ownerofpro,,my who builds or improves thereon,add PERMIT ISSUANCE Qa
who contracts forsuch Projects with acontracuals)licensed pursuantmthe Commuters
License Law. ALTER-DRAIN&VENT_WATER(EA) FEE SUMMARY
LI1 am exempt under Sea ,B&P C for this reason O IDE FE
BACK FLOW PROTECT.DEVICE
Owner Data SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA COND RECEIPTN
O SCHOOLTAX Y,_,N
❑ Ihereby affirmthat Insurance
marenifiets copyffieaent of(Sself-insure,or Lab C.)moofwhich FIXTURES-PERTRAP RECEIPfk
Wven at compensation Insurance macerified copy thereof(Sec.3g0o,Lab CJ which PARK FEE y N
coven all emlo ey e's under3 11 QUO GAS-EA.SYSTEM.1 INC.4 OUTLETS RECEIPT k
Ponapan ZeL/[IlC
'Company /�rp �p�+�E�sQ�J /{ GAS-EA.SYSTEM-OVER4 BUILDING DIVISION FEES
❑ CemRed copy is hereby famished (EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE .s tl _
(This section medical becompletcd ifthe permit is for one hundred dollars($10i SEWER-SANDA EA ENERGY FEE
or less.) // •�
1 ertify that in the performance ofthe work for which this permit is issued,tlkhall EI� M
not employ any person in any marmer so as to became subject to tine Workers .�ff PAID
7-. Compensation Laws of Califomie.
Data
O Applicant T S INtO / Date Receipt
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should R SI A F .FT. TOTAL:h become subject m the Workers Compensation Provisions of the labm Code,you roust
Forthwith comply with such provisions or this� permit shall he deemed revakW. G� TE BUILDING FEE
Q CONSTRUCTION LENDING AGENCY ;r ,..�rn'r^t • SEISMIC FEE
z 1 hereby affirm that them is a construction leading agency for the perfrnmance of
V0 the work for which this Permit is issued(San.3097,Civ.C.) -, TOTAL: J C ELECTRIC E
Lenders Name FE.,...
ULenders Address w QTY, MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that 1 have read this application and sum that the above information is
correct I agree to comply wirhall city and county ordinances and sante laws adding to PERMIT ISSUANCE •$ MECHANICAL FEE
III building construction.andhereby authorize representatives ofthis city menmr upon the
[� above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTROCHONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
babilities,judgments,costs and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in g
consequence of the'noun of this Fourth,
AIR HANDLING UNIT(OVER IBO(gl CPM)
Signature of AppdeaccuConowmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IIXI,000 BTU) — Date ReeeiptM
WIII the applicant or future building occupant store or handle hazmdans material
as defined by the Cupertino Municipal Codd.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00,"BTU) Q
Code,Section 25532DU
❑Yes CL NO VENTILATION FAN(SING F RESTIO
BOILER-COMP 3 h,1$SUAN�CE,(JATE
Will the appplarri orfuturebuilding by
Occupant Bay equAnd. it or Quality Management ( HP OR 100,000 BTU)
hazardous air comaminnms M defined by the Bay Area Air Quality Managemem BOILER COMP(OVER 100,000 BTU) AUGA
❑Yes MIN. NEW RESIDENTIAL MECH.—SQ.FT. S 14 19�y4��
I have read the hazardous materials requirements under Chapter 6.95 of the
C.lif can,Health&Safety Code,Sections 2.5505,25533 and 25534. 1 understand that CI IY ur
if the building does not currently have a tenant,that u is my responsibility to notify the VL I
Occupant of the requirements which must be met prior to issuance off a Certificate of
Ow r ranrhon dagen ��
TOTAL: ISSUED BY:
OF I