27606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
IILDIN -ELE TICAL PERMITNO.CIPY OF CUPERTINO PLUMBG-MFCHANI
CAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PRoJECIIUPN'I"IFICATIOry
27606_7COv
BUILDING ADDRESS: //a SANITARY NO. APPLICATIONSUBMITTALDATE
O / Y� UNITN /dIt" LOT# 0
OWNF. NAyy.1E: PrygQNpE: / /�y7/� CONTNA'IOR'S NA E: LIC NO: `
/ Q/ / OJrS es • a --6 079 edw A e h NIC CONTROL#
•ARCHITECT/ENGINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QI'Y. ELECTRIC PERMIT PEE
lee (foover -7 =606/ PERMIT ISSUANCE BLDG ELECT P9, W
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL gK�y JOB DCtiCRIPI'p10N
QWz I hereby affirm Nat l am licensed underpmvisionrof Chapters(commencingw hh
iWEE Scmiorce and
d of Division l of the Business and Profmsione Code,and my license is in PANELS L
yluC fail Lienal ClasseRect. v`
IQ,2W License Class Lic.p UP T02011AMP5
mGG❑y Date Contractor. 201.1800 AMPS
Z873ARCHITECTS DECLARATION OVER IM AMPS SQ.FIT.FLUOR AREA $/SQ.FU
O Z_G 1 understand my plans shall be used ae public swords.
ern(=8J I SIGNS ELECTRICAL
Qym�
Licensed Professional .13S 6
4K OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
��ad E:O 1 hereby affirm. Se that I am exempt from Nri Contractor's Co License I,uw for the
rl3wmG finhwwhich
(Section 7031.5,mos.S,Bus 911,land ve demolish,
Code:Aoriany
ay smacture TEMP.METER OR POLE INST.
M07 which rtts issu v#erminecires$applicitforsudemolish,file
rcpiig anysvucmm
CC QC) #norms licensed palsoret to the henisionntfthe Co permit License
La s(rambernChapter POWER DEVICES
tyK�p that heielicenuJp Section
ection 700 pro Division
of the Contractor's Litt nu Lomms Code)
aaxo�' 9(commmncing with Seaion'l1100)of Diviaion3ofN<Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or then he is exempuherefrom and the basis for the alleged exemption.Any violation of FIXlLRES SWITCHES- l—
F Z�- Section 7031.5 by any applicant for a permit subjects the applicant to u civil penalty of OUTLETS-
M� ern more Chun five hundred dollars(5500),
#rope y,ormyemployeeswithwagmniheirsolecompensadon, NEW RESIDENTIALELECTR _SQ.IT.
L $ ❑ hmowrk.andE n STORIES TYPF.CONSIRUCTION
will Pods work.and the rhacturne e Contrsnot s entled License La wedsed rsalt,nota ply t oan Business
wJ Professions Chic:She Comrecmle License Lew dres not apply to an owner of
pmpenywhobuipmvidmpmvuthimpmvements enauintend orroffemhroughhis OCC.GROUP RFS.UNITS
ownemployees,p building.,
improvement
improvemerrtsirenot imendedoroffcm.forsale.If,
bui der ,shebuildingorImprovementishathwithinoneyearerr ,improv for
purpose
of
hale.). will have the hasten of n that he did not build or ins for IOI AL.
Towing prove pury0u of
sale.).
❑ anowner unjfnhe t(Sec. 04al,Business and
contracting withlicensedConorttrsto QTY. PLUMB PERMIT FEE MOOD ZONE APN
construct the project(Sec.orano Business end Pwholnuins Code)The Contrwmfa
License Law doersuchapply toanawnconf ctpen)li ons pursimproveCorwctory P[iRMll'ISSU C
whocomraw.fursuch projectswitharonwctoKs)licenced pursunnuo Ne Convector's
Licrnu Law. ALTER-D By -WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis rtason nCK ROTECf.DEVICE, UPSIDE FEF.
SANITARY Y N
Owner DaIE RECEIPT#
FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION gCHOOLI'AX YN
❑ Ihereby ef8rm nhmlhnve ecertificita of conunuo ulf-insure,orerenificam of ftECE1PT#
PER TRAP
Wwkets Crmpensation lnsumnttmettrtifiedcopy lhcrwf(Sec.3800,LebCJ which PARK FEL YN
rsall employee's under this permit. RECEIPT#
Policy# GAS- . MM-1 INC 40fIr1.FTS BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(IA) PLANCHECK FEE
❑ Cendied copy is hereby furnished. ^�
❑ Certified copy is filed with the city inspection division. GREASr0NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifnhe permit is for erne hundred dollars(S 100) SEWER-SANITARY-STORM EA.2001,17. ENERGY FEE
orlers.)
I emify What in the performunceof the work for which this permit is issued,l shall WATER HEATER W/VENI'/ELECTt
not employ any person in any manner ser as to become subject to the Workers' PAID
z Compemation Lrov,of Celifomia. Data WATER SYSTEM?RIATFNG Data Receipt#
Applicant
z NOTICE.TO APPLICANT If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMB SQ.FT TOTAL:
tibecome subject o the Workers Compensation provisions of the Labor Code,you must
� .! forthwith comply wier such provisions or this shall be,dwmad revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SF.ISMICFEE 7O
I hereby affirm that there is a construction lending agency for the perfrrmena of
U 7" the work for which this permit is issued(See 301 Civ,C.) TOTAL: ELECTRIC FEE $ s
Lender's Name
O F Lender's Address QTY. MECHANICAL PERMIT' FEg PLUMBING FEE O
03 o-
U I cenify Than I have read this epplicuion and snare than the above information is MECHANICAL FEE
correct. PERMITFSSUANCE
3 �"8
lagree no comply with all city and coumy ordinwcer and statet�ws calming to
y building construction,and hereby auda iu representatives ofthiscity to eater upon the CONSTRUCTION TAX
U above-mentioned property for imprdion porpmer. ALTER OR ADD TO MECH.
(We)agree ,save.indemnify and keep harmless the City of Cupertino against
limilities,jud mens.costsind expenses which may in any waytecroeagiinnsnid City AIR HANDLING UNIT(TO 10,0110 CFM) # ^
in cons ceofthe granting of this permit. p
l AIR HANDLING UNIT(OVER 10,030 CFM)
Signature of Applicant/Cmalmerm Data EXHAUST FOOD(WMUCT) PAID
HAZARDOUS building
up.DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Duro Receipt
Will the the Coroner Muniipali Coide, gamer 9.or hnndlehazerdousd Safety HEATING UNIT(OVER 100,IroO BTU) TOTAL:
m defined by the 32(a)?no Municipal Code.Chapter 9.12,ind the Heal@ and Svfcry �r p
Cade,Swti 0255]2#)? VENTILATION PAN(SINGLE RFSID) U' {/
❑Yes ❑ Na
S E DATE
Will heapplicanr or future buildingwcupanmuequipmenmrdevims whichemin BOILF;R-COMP(3HP OR 100.01)(I BTU)
harardous air condominiums as defined by the Bay Area Air Quality Management BOILER 100,00(1 BTU)
District? JAS 241995
❑Yes ❑No NEW RESIDENTIAL MECH. SG,.PT.
ClIY Uh
1 d.H alta me hicrSafety
Cam materials 5505.25533 coder CliN. I mi a95 or me �LYrN
Curie buil Health&Safety Cade,Sections25505at it
and25534. 1undersmnd That
cshebuildingdoes not
mentscurrently haveareseal.Netit is myresponsibilityto notify the
Ocupant of the rrquirememe which must tc met prim no issuance of a Certificate of
Occupancy.
Owner in authorized agent Data TOTAL: ISSUED BY:
OFFICE