27844 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CCITY OF CUPERTINO B ILDI G-ELECTRJ AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL f]% O /I
BUILDING PROJECT IDEN'TIFICATU N L I o 4 4
Bf1ILDING ADDRESS: 1 SANITARY NO, APPUCYDON SURMI11]TAL,
lae DKM.
1�
I/"*- / �a UNITN Ice 11 -
OT# a1 --N
O Ii5 AME: PHON CONTRACTOR' AME:: ,C O: N/C _` CONTROL#cc�io� aiib n000 tsJ er
• RCHII'EJ /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/I //��.�s /�� QTY. ELECTRIC PERMIT PEE
/N Lp e V v{/ Cs N I/Q ��6 PERMIT ISSUANCE B ELECT PL{IMB M[CH
L[CF,NSLFD CONTRACTOR'S DCLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
Oyy I hereby affirm Nat l am licensed underprovisionsof(Talt(commencing with
P00c F2Sectin)of Divisionlof the Business and Professionx Code.anal mylicenseisin PANP.LS ^�
fE�F full lreeffed.Licensr,tc e Class—Lick UP T02W AMPS
m0. Date Contractor. 201-1000 AMPS
ZO asARCBIITECI-S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA VSQ.FT.
O Z—O 1 understand my plans shall he used as public records.
SIGNS ELECTRICAL
Q LicensedI fc sinnal O(
iEO 0.0.'' Q OWNER-BUILDER DECLARATION ON BPF.CIAL CIRCUIT/MISC.
NO c,
1 hereby affirm mm 1 oto exempt from the Contractors Cs License law for the
RJ to which following reason.
ernalSection
toon1.S,Business road improve,demolish,
or
city or county TEMP.METES OR POLE INST.
lst rn which mryi sic n permit to nmss'he alma improve,Demolish,fi repair any seucmrt
}� primtoslicenwcqulsu requires thevisiins ofthe CotramiuoLiease La smrtmrns POWER DEVICES
g' p that he is licensed pursuant to the .I'Di oto ofthe themmcsor's License law(Chapter
do� 9(cemmrncing with Section]100)of Division7of We Business said Professions Code) SWIMMING POOL ELECTRIC VALUATION
y _y miner be is exempt therefrom and she basis for lheulleged exemption.Anyviolation of OUTLETS-SWITCHES-FIXTURES /��
Z Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Ismalty of ('
=
or more than five hundred dollars($500L S
Cm m❑ I,asewnerofNeprnperty.ormyemployaswiN wegcseathcirsolecompemmion, NEW RESIDENTIAL ELECfIt FT. TY
Q' STORIES PECONSTRUC ION
n willdoduesork,and she stmctumis not intended moffered forsale(See 70,l Business
and Professions Care:The Contractor's License Law does not apply to an owner of
property wh.brilds mimpowesthereon,andwhod«ssuchwofk himselfurthroith his OCC.GROUP RFS.UNITS
ownemployers,provided that such i mproverren is are not i mended or offered for kale.If,
however,she building or improvement is sold within one yew of completion,the owner- 'TOi'AL: #Op
builder will love the burden of proving the,he did not build or improve for puse rpoof
s Ie.).
❑ I,aaownerofthepmpny,amexclusivelyconsmaingwithlicensW nv tonw QTY. PLUMBINGPERMIT FEE F1.00D ZONE APN
convect the project(Sec.761J,Business and Professions Cede:)The Contractors PERMIT ISSUANCE
m
Lice ulaw Jmxnrn apply man ownerofpmpeny whobuilJsorimprovesthereon,and
wbocomracts rsuch projects with aconvuctor(s)licensed pursuant to the Convenors
License Law. ALTER (EA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
• Owner Dare RECF.IPI'#
COND
AREA,, .
WORKMAN COMPENSATION DECLARATION DRAINS-PLDOR. SCHOOLTA% YN
❑ em'Co affirmtonimuve oraccmeofcor themf(Smure,ora bC.)am of RECEIPT#
Workers Cem FIXTURES-PER TRAP
pensation lmuranuoracenifeJ copy thereof(Sec.3tl(q,Lab C.)whicM1 PARK FF.E VN
overs all employee's under this permt. GAS-EA.SYSTEM.)INC.a OUTLETS RECEIPT#
Policy N BUILDING DIVISION MES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE �•
❑ CenifiedsHMisherehyfumished. All
❑ Certified copy is filed with ducity,impection division. GRVASEANDUSTRLWASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionnadma becempf,edifthe permit is forme hundreJ dollars PH00) SEWER-SANITARY-STOR)A EA.2MM'. ENERGY FEE
or les")
I cenlfy that in she performance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/ELECfR
not employ any person in any m o as to become subject to the Workers PAID
Z CompensationL swsof California.manner
a WATER SYSTEM/I'REATING Dwe ec ps#
Applicant
O NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
G7 y became subject to the Worker's Compensation provisions ofthe labor Cod,you must
a ; forthwith comply with such provisions or this permit shall be,domed invoked. BUILDING FE-1.7N'
L
W Q CONSTRUCTION LENDING AGENCY SEISMICFEE
1 hereby offum sbnnherc is a construction lending agency far rho peRormance of
V O the work for which this permit is issued(See 3097.Co.C.) TOTAL: /*76,0.r ELECTRIC FE-E Nr
larders Nome PLUMBING FEE
Landes Address Oa QTY. MECHANICAL PERMIT FEE
0. 1 certify agree to 1 have read this city
and
and atom that the above information is MECHANICAL FEE 7 O r
V) wncng constmcumply with hereby all cltymmd cmentyourive ofthis nmclaws r upon
m PERMIT ISSUANCE V
U IA abscre-menritedpmparr hercbspectiri purples. Lives of Chia cirymenrer upon the
V 7 above We)honed pmpve,indemnify
inspection li id keep for. ALTER OR ADD TO MECII. CONSTRUCTION T S^�
C (We)agree m sums,indemnify and keep harmless Ne City of Cupeni against
liabilitics,judgments.cone anal expenses which may in any way accrue againstt said
said Ciry AIR HANDLING UNIT(TO IO,p00 CFM) a �
inconuquen of the granting of this permit.
`/�,v/fj� AIR HANDLING UNIT(OVER 10,M)CFM)
I" /fes'
Sig ureof AppIterm/Comrvc /7r—XZ Da =te EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"BTU) Data Receipt#
Will the applicant or future building occupant store or handle harardous material
as defined bythe Cupertino Municipal Code,Chapter 9.12,and the Health and Safety BEATING UNIT(OVER 100,0g0 BTU) TOTP
Coda Section 25532(q?
0Yes C1 No VENTILATION PAN(SINGLE RfSID) 'ySb� a
Will BOILER-COMPQHPOR100,"BTU) ISSUANC 7 1995
hhe upplicantorlmure buildingxcupvm useequipmenmrdeviceswhichemit '
• hmnork us air contaminants m defined by the Bay Arta Air Quality Management BOIL HR-COMP(OVHR 100,000BIU)
Dismet? ❑ CI I Y Ur
Yes ❑No NEW RESIDF.NTIAI.MECH. SQ.FT. (aUYCfy I IN
I have read the haaalloua materials requiremems Order Chapter 6.95 of the
California Health&Safety Cede,Sections 25505.25533 end 25536. 1 understand that
if the building does nut currently have a mnant,that it is my responsibility to notify the
occupant of the r maclom/'mal which mmuu`stt he met prior to isauana f a Ce 'ficam of
Owcnerwcywhod.ee 4 ��5�
TOTAL: I 74 ISSUED B .
OFFICE