27220 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL IIING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING FROG CT IDENNICAI, 27220 7 2 2 O
BUILDING PROJF.ITI'IDF:NI'IFICATION L I
BUILDINGGAADDRFSS: SANITARY NO. APPLICAATTIONSUBMITTALDATE
O--w / V,a lLe ,' UNIT» Y lQ 3 LOT» 3
O FRS NAME E:PHONCONTRACTOR'S NAME: LIC NO: CONTROL»
i afi0 Ome N/C
B 5-66127 Ocuner
RCHITEC/ENGINEER: LIC NO: ADDRI3S: ❑
CONTACT: PHONE
1 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
IN e V�� e Op OV p(.o� PERMIT ISSUANCE B CLF.CI' PLUMB MECH
Kpu( .Fk�jFf
LICENSE9 CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ihereby affirm the,I are licemadumen
ndolunwisiorx.faidde,9(comting with
[s W E Section]Opal)e f Division l of the Business and Professions Code,and my license is in ppNE1.5
CU� fallLicense
foree.anse Cladeffect. v\ I
F2,W Liccnu Class Lic.p UP T0200 AMPS
6y Date Contractor 201-["AMPS
ZOr`niaZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.IT.
1 understand my plans shall M used as public records.
rqt`Yn u� SIGNS ELECTRICAL iQ
M' Licensed Professional �( b
g [�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUTIUMISC. ��
O y F 1 hereby affirm that 1 am esempt from the Commentr'a License Law for the
"30va following maim,(Section 0031.5,Business and Professions Code:My city or county TEMP.METER OR POLE INST.
tS�1 which requires a permit to construct,alter,improve,demolish,or repair any structure
CtaQ2 primmitsism...e,alsorequirestM applicant for such pemsiUo fle.6lourirroment POWER DEVICES
tyq p that he is licensed pursuant to the provisions ollhe Contmctars License law(Chapter
Lqo oC, 9(commencing with Section 700do.f Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—a Sectionat 703 exempt LSbyinherefromend Ne basisfor
trNeellege.,fication. civiny 1prnaltyof OUTLETS.SWITCHES-FIXTURES as`9;
7- Section than file
hundred
subjects the epplicanno ecivil pendty of
nm more thin rive hundred dollars(ESfg).
W a I..ownerofthepropcny,ormyemployaswiNwagesaatheirsolecompc..tion, NEW RFSIDPNTIALELECfR _SQ,FT. STORIES TYPE, TI
CONSTRUCON
W 3... will do the work,and the structure is not intended or offered for sale(Sec.70H4,Business
and Proles ons Code:The Contractors License law does not apply to an owner of
property whobuitdsorimprovesthcrcon,and whodoes such work himseIfofthrough his
ovoemployces,provided that such improvements are nm intended oreffred forsale.If. OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofcnmpletion,theowner- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
sale.).
❑ I,.ownerofthe Wopeny,mnexclusivelycon=ting Ml lirensedcontractorsto QTY. PLUMBING PERMIT PEE ILOODZONE ArN
e.man m the project(Sec.9044,Business and Pro@.,ions Coded The Contractor's PERMIT ISSUANCE
License Lawdoes nm apply Iran my...f progeny whobuilds or improves thereon,unJ
whocnntmcts fm such projects with acontracmtl)licensed pmsuanamhe Correctors
License Law. ALTER (E
) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this motion RACK FLOW PROTECT.DEVICE. SIDE S
SANITARY Y N
Owner Dal[ RECEIPT»
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ en'Co affiamthmnsura c nce oraceetif ofconunttoaff(Sesure,m Lob C.)which
RECEIPTp
WorkFIXTURES-PER TRAP
covers llemplyeasool.thisporoartified copy therwf(Sw.3g00,LobCJwhich PARK FEE Y N
covers all employee's undo this pcmmif GAS-FA.SYSTEM-1 INC.4 OUTLETS RBCEIPT p
Policy» BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEB
❑ CCnIBed Copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEF?
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sec tion neednm becompleted if Ne permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEC
or loss.)
Icenifythet in the performance of Ne work for which this permit is issued,)shall WATER HEATER WNENTICLMTR
not employ any lemon in any m as to become subject to the Work[ma' PAID
CompenadfmLawsof C.lifomie. Date 10 WATER SYSTEM/rREATING Dam Receipt
zO NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
> hecmar hwithejec ,solo...kersCompensation
nsorthisPermitshallkithe
mosiJ s.ked. must 1� a-
forthwith comply with such provisions or this Permit be deemed rcvokM. BUILDING FEF.
4 ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE N 70
�r-s I hereby afftun that them is a mvtruction leading agency for Ne pertomance of t
V 0 the work for which this permit is issued(Sce.3097,Civ.C.) TOTAL: ELELTRIG FEF. 'Ora V
lender's Name PLUMBING FEEL) I<nder'aAddress QTY. MECHANICAL PERMIT FEE 3, p
L) 1 certify that I have read this application and stoic that the shove information is
cornet. Iagree to comply with all city and county ordinances and state laws misting to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives ofthis city toenterupon Ne CONSTRUCTION TAX 3
L) Z above-mentioned property for inspection purposes. AUI'1?RORADDTOMECII.
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
I iabilities,judgmums,costs and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO 10,000 CFM)
in coB�yence of Ne gtvNng of Nis permit.
L/ 'Ls i I q r AIR HANDLING UNIT(OVER IO,OW CFM)
�t. / (�' 7 EXHAUST HOOD Signewm of ApplicanVConvu or Dom PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO[WM BTU) Date Receipt0
Will the applicant or future building occupant store in handle havrdous material HEATING UNIT(OVER I W.IXq BTU) TOTAL:
as defined by the Cupertino Municipal Cade,as,.,9.12,and the Health and Safety
Coda,Section 25532fe)'!
❑Yes ❑Na VENTILATION PAN(SINGLE RISID)
ISSUA E DATE
Wilhhe applicant orfuwm buiidingoccupentuuegoipmrnmrdeviesswhiehemit BOILER-COMP(JHA OR IW,IAIp BTU) f�q
hazardous air comm assets us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P' B D
• Uistricrl
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the ^ JAIL 24 199
California Health&Safety Code,Sections 25505.25533 and 25534. 1 undersand that Yt/
i r the building does not currently have a tenant,that it is my responsibility to notify the O/ � V1• Wr
occupied of the Issluirementa which must be met prior to issuance of a Ceniftcate of
Occupancy.
Owner or anthorieed ogem Date TOTAL: ISSUED BY:
OFFICE