27215 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO Ell,II'D1RU--ELEL'TRICAI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING ADDR DIVISION BUILDING PROJECT IDENTIFICATION
27215
BUILDING ADDRBSA _ / SANITARY NO. APPLICATION SUBMITTAL DATE
O(V O—/ (I/Q� �QL ,0, UNITN / � LOTH `�
O TRS NA F:: PII F,: CONfRACI'OR' NAME: LIC NO: N/C CONTROL
a iCn eM Z 9 - OGS curt �
• ARC[ItTEC'DENGINEER: PIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PER BUILDING PERMIT INFO
TELECT PLUMB MECH
EAw
9 X XV
D
LICES CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION W
ZA&Z I herebyaffirm that l am licensed underprovisiomofC ,ter9(commencingwith
+100 Section] of Division Jafthe Business it Pmfaeinru Code,and my license is in PANELS FZ
ty ul And full fora and effect.
F Z W License Claus Li<.N UP TO 200 AMPS
m Q y Dam Corummt MI-1000 AMPS
ZDyZ ARCHITECTSDECLARATION SQ.IT.FLOOR AREA S/SQ,FT.
1 understand my plans shall be used as publicrecords. OVER 1000 AMPS
oz � ver i
F'rn SIGNS ELECTRICAL
Licensed Professional
W U that
I at BUILDER DECLARATION SPECIAL CIRNIT/MISC.
O a t- I hereby Affirm that I um exempt from the Contractors License Isw for the
40 Q following reawn.(Section]OJLS,Business end Professions Code:Any city m county TEMP.METER OR POLE INST.
rn J which requires a Perm to comruO,elmr,improve,demolish,or tepdr any mmeture
IyD]},X prim to its issuance,also requires the Applicant forsuch PermRm file a signed statement POWER DEVICES
pI CSO that he is licensed pursuant the provisions of he Cnnaauees License Law(Chapta
°'acff 9(mommeming with Seed..7")of Division 3 of the Business and Profusion Code) SWIMMING POOL EL.ECf¢IC VALUATION
WZ m or that h7031.5 by therefrom and the Permit subjects
is the
exemption. civil Penalty
of q 6�3.
WM, or that Section he ise em Any applicant for erefromandte basis f rtje allege exemant n.Any 1penny of OUTLETS-SWITCHES-FIXTURES
1sQ not awred.ri Eve hundred dollms(S50B.
-0 ❑ I,usownerofthe propeny,ormy employmnwi,h wagesustheirsolecompensation, NEW RESIDENTIALELECTR _SQ.FT. STORIES- TYPE CONSTRUCTION
a32 will dothe work,and,heswctumis not intended croffcred forsde(Sm.]044,Businees
and Pmfeesinns Cale:The Courtrai License Law does not apply to An owner of
property who builds or improves thereon,andwhodoessuch work himselforthroughhis
own OCC.GROUP RES.UNITS
employees,providedthatwchimprovemrnthin nn yonar fecoroffered fmsele.If, •fin
howeer will have
buimprovcmcmissat he within build or impane fnd purpose
TOTAL: N.
builder will have the burden of proving that he did not build m improve for purpose of
sale')' QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
cons❑ I,n the pr ject(Sro,70", Bustles andly amProfessio widen ds:)Th convmmtsm
ice rucr the oesnot(Sec.](w4,Business and ywhobians Cade)The Contractor's PERMIT ISSUANCE
Li cense Lsw ds not apply ct an owner of property li bo builds ra improv es Nermn,and
wheaPormch projects punuanuo Ne Consmcmts
Licensence Law.
ALTER-DRAIN&VENT-WATER(EA) FE•ESUMMARY
❑ 1 Am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Dam RECEIPT p
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP.AREA,COND. SCHOOLTAX Y N
❑ Thereby affirm that l have acenificate ofemsem to self-insure,or a certificate of RECEIPT At
Workers'Compensation fimuranceara eartifiedcnpy thereof(See.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
meets ell employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPT p
Policy p I BUILDING DIVIhSION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE OL�
❑ Certified copy is hereby famished.
❑ Certified copy is GlM with the city inspection division. ORE- SE(INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifhe permit is furore hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF.
orI aJ
Iceloy that in the pIAonnwreeof Newoh for which Niubject tisihe Workers'
WATER HEATER WNFNf/ELECfR
not employ any person it any manner so m to become subject m the Workers' PAID
Compensation Laws of Cdifmde. Dam WATER SYSTEM/TREATING Dam Rmeipsp
O Z Applicant
z NOTICE
suj APPLICANT:r's after Compensation
this Cu inmate of Exemption,
.youshould NEW RESIDENTIAL P MB. SQ.FT. TOTAL-
DO become compto thely
with
Wader's Compensation prmitshallns of the Labor Cooked. must /
forthwith comply with such provisions of this pcmdt shall be domed revoked. BUILDING FF.F. OeO a ��
4 (]
CONSTRUCTION LENDING AGENCY SEISMIC FEE 5 D
U z 1 hereby affirm that share is a mnsnuction lending agency for the perforunce ofq
U O the work for which this p<.it is issued(Sm.3097,Co.C.) TOTAL: `�i ELECTRIC HIE / 70 Q `-
Lender's Name E NG FEE E
U Lenders Address QTY. MECHANICAL PERMIT FEE PL04-
�•' 4U I certify that 1 have read this application end state that the been information is MECHANICAL IEE 7 0 O S--
coned I agree m comply with AT city and county ordinances end state laws relating to PERMIT ISSUANCE
buildingcunsuuction,andherebyauthorizerepresmtafivaofNiscitymenteruponthe CONSTRUCI'IONTAX 6 a s9
U 7 ahove-mentioned property for inspection purposes. ALTERORADDTOMECIL
0�- (We)agree to save,indemnify and kap haradeas the City of Cupertino against / Qa �—
Imbilifiks.judgments,costa and expenses which mayin Any waymmuc aunssdd City AIR HANDLING UNIT(TO BLOW CFM)
in flLe granting of this permits AIR HANDLING UNIT TONER 10,000 CFM)
c�.o..� P.-� a � I� � EXHAUST HOOD Signature of ApplicunVCom cast Ue,e PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GO 100.100 BTU) Date Receipt At
Will the upplimm or fawn building merpant store or handle hazallous emend HEATING UNIT(OVER 1(X1,000 111 U) TOTAL:
es defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health And Safety n
Cale.Section 25532(x)? VENTILATION PAN(SINGLE R[5ID) O(
13 Yes 11 No
ISSUANCE DATE
Will the applicantorfuture buildingoccupant useequipmen.rdeviceswhichemlt BOILER-COMPUHP OR 10p00 BTU) q
harurdous air conmminams is defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1110,(X10 BTU) PA � A
DisOie? V
CI Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the ha zcdmu emends requirements under Chapter 6.95 of the /995
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
ifthe building does not currently have u tenant.that it is my responsibility to notify the C yvP �.
occupant of the requirements which as,be met prior m issuer.of a Cenif¢me of
Occupancy. lzzo�s .f fU
Owner or..danxed agent Date TOTAL: /a ISSUED BY:
OFF C