27692 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO 11III1,UI C-hLh'TRICAL PHRMITNO.
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27692
BUILDING PROJEC 1'IFICA
IDEN'
BUILDING ADDRESS: ` l SANITARY NO. APPLICATION SUBMITTAL DATE
aIr11Z..A G 7✓ / � I �,D 11l—lUNl LOT#
O Sry}AME: PHONE: C LA`CI'O_R' AME: O.
11 4Z'G/1�1 6r� GJ y ft`�yag/�g�.�1 C� rCC4J �Z N/C CONTROLp
• AII' yT/FVNh �J NHER LIC NO
❑
CD �b PHONE: BUILDING PERMIT INFO
yrE y QTY. ELECTRIC PERMIT FEE
�'�, v J d 7/z—Q� PERMITISSUANCE Bif LDG ELECT PLU❑MB MO I
LICENSED CONI RACfOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
C=z Hu ehyef anothatlam licrnud undcrpmvisions ofChepmr9(commencing with
Pu00 Section"IUW)af Divisio 3ofthe Busirmsn mA PmPossio Code,and mylicemeis in PANELS
ytE fullfnmenndeffect. �/
Z W Licenx Class Lic. ��� UP]'0 2(g1 AMPS
co=y Oate Contractor 201-I0p AMPS S G FT.FLOOR AREA S/SQ.FT.
z FON` ARCHITECTS DECLARATION OVER 10011 AMPS Q
O2.—c - 1 understand my plans shall be used as public recons.
pN SIGNS ELECTRICAL
LlannW Profenslonul
Wec6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaO I hereby n(Se that I am exempt from the Cosions Ca e:Any
law for the
LL 3 LL y which
following son.(Seat 1.Or ourcLBusinessie,improve,
Professions Cade:Any dry or county TEMP.METCR OR POLE INST.
(_nON; whichrequiresn permit reuiresrthealmaimprove,demolish,arrepair anysanctum POWER DEVICES
ndY� priono its issuance,also requires the applicant for such permino rile singled statement
yl0y'<0 9 Emin eiry licir,.uensuall uncdcal7013).uant to the r ivis of.fldhe Conaaaess License Law(Chapter
SWIMMING POOL ELECTRIC VALUATVW ON
LLLLo� 9(cammenexempt therefrom
and
dthe Division Sof theedesesand Professions Code)
1=KK orthm h7031.5 by ary. lie mfar. ammior themthedexemption.Any violation of OUTLETS-SWITCHES-FIXTURE$
FZQ Section]031.5iv anydped dollforupennitsubjectsrhe.pplicannoacivilpene0yof
��O
not marethmfive handled dollars;($500d. NEW RESIDIiNTIALCLECIR _SQ.FT. STORIES TYPECONSTRCDON
e ❑ L asownerandrheaperty,a is ,mployedmidleardorsaleirmle compensation,
will Jofesion,ande:Thic tara e,lia'ntendese La a does out
a ply(SeeV,anown7044, erof
ness
anJ Profeasiom Code:The Conm.nore License Lew does not apply w m owner of
property whobuildsor improves thereon,andwhodoessuch work himselforthrough his OCC.GROUP RES,UNITS
employees.pmvidedthatsuchimpmvemenmamnmimendedmofferedforssla If.
however,the building mimprovement is sold within one year ofcumplctian,theowner- TOTAL:
hadder will have the burden or proving that he did not build or improve for purpose of
sal`'). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lan the pmject pmpeny,1. exduxlven rnnaaating with licemedcoommuca s
ooawa the project Ses.pply]�no Business pe professywhobuild Cale:)The there acmr'e
License low Joesnot epplymun owimrof property who builJs ar improves thereon,end PERMIT ISSUANCE
whocontractsforsuchpcnats with aconavcmr(s)licensed pubmanumhe Committees ALTER-DRAIN&VENT-WATER HA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. ,B&PC for this reason FEEN
BACK FLOW PROTECT.DEVICE U .IDL
SANITARY Y N
Owner DateRECIA .1
WORKMAN COMPPNSA'110N DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
�.Ihereby affirm thatlM1nveacenifcnm of conunnoself-iv......omificatenf Fl%TURES-PER TRAP REC IPT#
Workers'Compensation Insurance or.cenifiedcopy Nermf(Sec.38W,LbCJ which PARK ITE Y N
covers all erpglgyej'sa�der tliweryt_. 07G �f8d'—bl NGAS-CA.SYSTEMT1.
-IINC.40UHT5 R EIPTN
Policy WV GG.• !!6611 BUILDING IV ISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK Ff
❑ Ceni y,.Cm nish d.
*. Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRAD!—.EA
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIL PEE
COMPENSATION INSURANCE
(This sermon neeJ not be completed ifthe pcmtit is torose hundred dollen(5100) SEWER-SANITARY-STORM EA.200FT. eRGY cE
or les,)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/EI.ECIR
not employ any person in my manner sec as to became subject to the Worker' P
z Compensation Luwsuf Califumia. Date WATER SYSTCMTRGTING Dat Receipt#
Applicant
ZZ�O-i NOTICE.TO APPLICANT:IEafter making this Cenificale of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
L—' becomc nuhjectd
to the Woc/s Campens.d.provisions of the Labor Code,you must �a
FF" forthwith comply with such provisions or this permit shall be domed rovoked. BUILDING FEE 'L
fA Q2O
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the p,rfommnce of
U O Fern TOl'AI.: ELECTRIC FIREthe war,for which this tis issued(Sec.1091,Civ.C.)
Leader',Name
u" � Lenaders Address QTY. MECHANICAL PERMIT PEE PLUMBING FEE
D W 1 lenity the I have mad this application and stem that the above mformatian is
coma.I agree m comply with all city and county ordinances and state lows relating to PERMITISSUANCE MECHANICAL FEE
C" huildingconsaunion,and hereby nth cow representatives of this city to enter upon the
L) z CONSTRUCTIONTAX
above-memiune ropmy for inspection purrwses. ALTER OR ADD TO MECH.
(We)ag u ,inde dy and keep harmless the City of Cupertino against - p�
Babilithisju mesa csm hich may in any way,ecom.guinst said City AIR HANDLING UNIT(TO I BWB CFM) 'l
in conscyu cat gm a
AIRIIANDLINGUNIT(OV-ER 10,000 CFivD iqu
Sig ,am or AppllwaVGoplmcmr Dne - / EXHAUST HOOD(W/DUCT) PAID 1994
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU Data et t
Will the applicant or future building occupant store or handle haammus material OTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,"BM)
Cade,Secdon 25532(.)? VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
ISSUANCE DATE
Will heapplicanmrfumre builiingoccupmtuseequipmem mdeviceswM1ichemit BOILER.COMP(3HP OR 100,000 BTU)
huvnlms air contaminants.s defined by the Bay Arca Air Quality Management BOILER-COMP(OVER U0,030 BTU)
•
District?
13 Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hmeMous materials requirements under Chapter 6.95 of the /
California Health&Safety Code.Sections 25505,25533 and 25534. I understmd that o'
if the building does not currently have a Icnant,that it is my responsibility an notify the
occupant of the requirements which must M met poor to issuance of a Certificate of
Occupancy.
Owner of authonacd agent Date TOTAL: ISSUED BY:
OFFICE