27210 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO
BUIL UI G-ELECT'RIC'AL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING- rIDENTIFIC 27n�I O
BUILDING PROJEC'1'IDENTIPICA'I'ION G G 1
BUILDING ADDRESS: R SANII'ARYNO. APPLICATIONSUBMITTALDATE
a O/�♦ UNITN P&PI LOT at 13 :2
11�
O ER NA E: PHONE: CONTRACfOg'S NAME: LIC NO: NIC CONTROL It
% a l org emrs 9 5-6007) ()tun eI'
• ARCHUECDENGINEF.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. EI-CCI'RIC PERMIT PEE EUILDING PERMIT INFO
Be Cobert. 9$5-606/ PERMIT ISSUANCE BLDG ELECT PLUMB MECH
LICE BD CONTRACTORAPPLIANCES-RESIDENTIAL S DECLARATION �` g
Manzand IOB DESCRIPTION
P400 IherebyaffrmmaU 3 ofth Rashness
Puiowions Cer9(commencing with
WtE[ S«tion]OIIIit of Divisinn3of the Business and Professions Code,and my license is in PANBLS /�. y1
aZ, falloe class eR«L /^ U
F2m License Class Lit, UPT02W AMPS
y<y Dare Contractor 201-I"AMPS
ZOmz ARCHITECTS DECLARATION OVER IOOIIAMPS SQ.FT.FLOOR AREA $/W FT.
oz-0 1 understand my plans shall h used as public words. _
f=22 � SIGNS ELECTRICAL �
qyy J Licensed Professional O( U b ���sffVJJ
°5y�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUITMISC.
�pS..0 1 hereby afford that 1 and exempt from the Contractor's License Law for the
st+3QvFi following reason.(Section 1031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE.INST.
(3 w which requires a permit to construct,alter,improve,demolish,or repair any structure
p�u�'T� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
ty C 00s thin 11 11 licensed pursuant to the pnrvisions of the Contractor's License Low(Chaser
d6�feW 9(commencing with Section 1000)of Division J ufine Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
Blom or thus he is exempt therefrom andthe basis for Imidleged exemption.Any endiumeof
F-
Section 7031.5 byanymFlicnn for.pmradmbjects theasplicturi civil pe.At,.f OUTLETS-SWITCHES-FIXTURES L
'� G not more man live hundred dollars(S500). �/ 6 ��♦ c/
04 ❑ I.mowncroft e n NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
y3o0_ propc y,ormy<mployeeewithered f asthei(Sit,7 m.Basin.,
will dnthewons ande: bl Cmelsnotint icenseofwdoe err or apply I.an Business
and Profusions Code:The Con thereon,License ocir does not apply ro an owner of
property who builds or improves rherwn,and who does such work himself err through his
I «a,providedmetsuchim OC GROUP RES.UNITS
wnemp my tnsuld hire neyou, feturofti.a,mome. r-
M1oweveethebuildingnrimprovememissoldwithinoneyearofrompletion.rhe owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale).
❑ 1,asownerofthe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT PEE on ZONE qPN
construct the project(Sec.10x4,Bus and Professions Code:)The Contmctore
License Law datn,am apply toanownerofpropeny whobtildsmimsrovesmre
eon,and PERMITISSUANCE
who contracu for such projects with aconlmcmt(s)licensed pursuant to the Contractors gLTI?R-DRAIN&Vf:NT-WATCR(FA)
1.icerue Irw. FEE SUMMARY
❑ I am exempt under Sec. B&P C for this meson BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE Y N
Owner Date RECF.IPI'p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihembyaffrmthmlhaveacenificnte of canunuo self-insurt,aro«nifne of RECF.1PTa
FlXTURFS-PER TRAP
Warkers'Compensatimt les urancenrecenifed copythemof(S«.3800,Lab CJ which PARK FTE YN
coversallemployees undo this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT N
Policy N 77ES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished. 0 to
❑ Cmified copy is filed with the city inspection division. GREASEINDUS'IRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifine permit is forome hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I mnify mm in the performance of the work for which this permit is issued,l shall WATER HEATPR W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
z Cmmpeasationitawsof Celifimia. Dae WATER SYSTEM RFTINC Dee ReceiptN
Applicant
z 0 NOTICE TO APPLICANT:If.after making this Cenifcaeof Exemption,you should NEW RESIDENTIAL('LMR. SQ,PT. TOTAL:
r 4 bccomesubj«ua me Worker's Compensation pcwhimd.fthe labor Code,you must
7 fonhwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE e 70
(hereby affirm that there is a construction lending agency for the performance of S
V C) me work far which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U Lenders Name PLUMBING TLE -
o Lenea !/ders Address QTY, MECHANICAL PERMIT FEE aG Jp S
I artity the 1 have reed this ntmn coand sue that me above information is
�" LkI eer.IugreccomPlywith all applicationcity and county
nty ordiordinancesreadinans d state laws relatingto PERMIT ISSUANCE MECHANICAL FEE
E' W) building construction.and hereby vuthorim representatives ofmis city toemer upon the CONSTRUCTIONTAX 6
(„) Z above-memioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way wermigaimasaid City AIR HANDLING UNIT(TO 10,000 CFM) �—
incorlLeWenceoIda e ming of this permit. / AIR HANDLING UNIT(OVER 10,000 CFM)
$ignawreof ApplicwUContinuum Oae EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IO(ifoO BTU) Dam Receipt#
Will the applicant or future building rampart store or handle hazardous material TO as depend by me Cupertino Municipal Cate,Chapter 9.12,and the Health and HEATING UNIT(OVER 100,IXIf BTU) TSafety �s rAL
Code.Section 25532(u)] VENTILATION FAN(SINGLE RPSID)
❑255 ❑No
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will eaountionneirls rebuilding by pantuseequip Air
Management
P A D
haewdous air contaminants es depend by the Buy Arca Air Quality Management BOILER-COME(OVER 100,000 BTU) Ir P� ,
District?
CI Yes 0 N NEW RESIDENTIAL.MECII. SQ.FT, 99
.��� �$A 1995/A�
I have rend the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
if he building tines not currently have a ennnt,that it a my responsibility oil. re notify the CITY e,1i►Ey+t'�i'.�TIIIVU
if he but of the requirecom which must be met prior m issuance of a Cn wofifm of
he
O«apancy.
Owner or authorized agent Date TOTAL: ISSUED BY:!�
OFFICE