27843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO Bmrrslnz:-ErecrnACA PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PI-UMBING-MECIfARICAL 2 7 8 4 3
BUILDING PRGJECI IIIENI'IFTCATION
BUILDING ADDRESS:���� //y� 9 SANITARY NO. API'LICATIONSUBMHTALDATE
Ka UNIT# ///J�IQn I \ LOT# / I L_i aaal�q
HIS AM PHONE: CONTRACTOR'S NA�1s LIC NO:
l a� NIC CONTROL#
• AHCIIIIT:CT/fiNGINEER: LIC ADDRESS: l/s.V ❑
CONTACT: C PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMI"1'INFO
y S 606 PERMIT ISSUANCE
BLDG ELECT PLUMB MECH
LICENSED CO RACTOR'S DECLARATION APPLIANCES.RESIDENTIAL IR�Y JOB DESCRIPTION
.CNJ'f
QWz I hereby affum Nat l sm licemW undrnpmvisio®of CTapter9(commencingwith
P02
oil to I force and effectvision 3 of the Business and Professions Code,and my license is in PANELS
6 VVy
Data cen"aClaes O
Contractor 201TI0110 AMPS
FyZ ARCHITECTS DECLARATION �Q.F�. 11riFA 5/SQ.FT.
Z.Oy^ OVER IBM AMPS ,L J
oz—a lundentandmy plans shall
be used as publi<records.
(=Y SIGNS ELECTRICAL
Q licensed Proessiol
fna
Ed;�V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
WOgF 1 hereby efOw that 1 am exemin from the Cmions Co License Lew for the
W 3 6.y following reams,(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
VI C"" which myuiresapewit mconswcL alter, demolish, myswcmm /}}T
IsyI�<0 prionnits issuance,alsoregniresthe applicmtfur such pewiuo fileadgned smemem POWER DEVICES {/V
µ�j K p that he is licrnsed pursuant to Ne provisions o(the Contrectols Licenu law(Chapter
dXp� 9(annmmcing with Section](MIO)of Division3of the Faminessand Profession Code) SWIMMNhO POOL ELECTRIC VALUATION
Of Seen 7031.emlnNerefromnrmd the basis for the ellegWpoicanexemption.Any viipentimn of OUTLETS-SWITCHES-FlXTIIRES ('^�a
I—z,Q no,m mom
v mndred cam s($50%it eubjema the applicvnnUecivil penahy of 4:119) U
nal mom than five hundred dollars(Seg). NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
C m ❑ othe wrk.and
is not faoyedoraffiercal Ion wagesavhe'(sole compmaedon,
y will dothewons ende:Themreisnots Liecdo Law
apply to
Business
pmpmy Professions Coon:The Conuumors License Law does not apply to an owner of
.vnero wboboilovidedproveuch improvements
monotcneadedimuendlthrough his
wnemployees,pmvidedthat such impnrvemems wenotinundcdoroffercd Tarsale.If, OCG GROUP RES.UNITS
however,the building mimpmvemem is sold within one yearn erampletion,th,owmor TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
fu1c) ted QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,ct the Project
cep 7(,am Business add ommcd las C dee)Ti cCommersto
License the project pply oana acrofu and ywhoPraftdon coded Toe Contractor§
Licenu).aw,forsuh pplytaanowacofpropeny whnsed or peanut
to the therms,and PERMITISSUANCE
wicensemcts forsuchprojecss withacnntnctot(q licensed pursunnuo the Conwctols ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
❑ I am exempt under Sm. ,B&P C for this won1 F
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dau DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
MAN COMPENSATION DECLARATION SCHOOLTAX Y
• co WORKN
❑ Ihcrcby effiwtbatlbeveecenificum of ronunna self-i....orattrtificvuof RIiCE1Pfp
Wnrkcrs'Cnmpensatin Insurance orncenifieJ copy thereof(Sec.3g00,Leb CJ which MIXTURES TRAP PARK FEE Y N
ars al l employee's Under this permit. GAS-EA.SYSTEh1.1 INCA OUTUTS RECHIPT p
Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(HA) PIANCHECK FEE
❑ Cenified copy is hereby furnished.
❑ Certified copy is filed with Ne city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE IV
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE I IV
COMPENSATION INSURANCE
(This section need mat he completed ifthe permit is foram,hundred dollars(SIM) SEWER-SANITARY-STORM EA.20OF7. ENERGY FEE
or less)
I cenify that in the perferrnance of the work for which this pewit is issued,l shall WATER HEATER W/VENT/ELECB
not employ any person in any manner so u in become subject to the Worker% PAID
Compenation Lowsof California. Date WATER SYSTEMTRF.ATING Receipt#
O Z Applicant
Z 0 NOTICE TO APPLICANT:If.Offer making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.PT. TOTAL:
�2 become subject to the Worker's Compensation previsions ofthe Labor Code,you must
a
(onhwith corn with such provisions or this i , comply p .it shill be deemed revoked. BUILDING FEE /
I
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O
1 hereby affvtn Nat them is a constitution lending agency for Ne performance,of
V O the work for which this permit is issu,d(Sce.3097,Civ,CJ TOTAL: ELECTRIC FEE 3 SSa
QULender's Nome PLUMBING FEE p.p
Lender'sIe Address QTY. MECHANICAL PERMIT FEE pJg S�
I cenify that 1 have read this city
and iou and swe Nm the above information is
W MECHANICAL FEE
curter.)agree to comply with all city and county mdinmca and state laws relating to PERMIT ISSUANCE 183, S
h building cans[ruction.and hereby authorize repuuntatives oflhis city to enter upon the CONSTRUCTION TAX
U Z move-mentioned pmpeny for inspection Im".1. ALTERORADDTOMECH. Sul 6-17
(We)agree to save,indemnify and keep hawless the City of Cupertino against
liabilhics,judgmenu,costs end expenses which may in any way accrueagainst said City AIR HANDLING UNIT(TO I0,1100 CFM) OG
in cnnseyuencyyyyyyfo, grenring (this pewit, e
�J /J / �� ��jyi AIR HANDLING UNIT(OVER Itl,00t)CPM)
Signal eorppplicamaCoo�mrucke ^_/ /y-'-i�--DatCe EXHAUST HOOD(W/DUC1)
PAID
HAZARDOUS Ming occupant
DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dau Receipt#
Will the the Cupertino
or future building de,C am sure or handle hazardous materiel
m defined by the Clpenino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BN) 'TOTAL:
Cad<,Section 0Ycs ❑No 2S532(a), VENTILATION FAN(SINGLE RESID) a
ISSUANCE DATE
Will upplicvnlor fuwrebuilJingrccupamuse equipmenmrdeviceswhichemit BOILER-GQMP(3HPQR IW,0)0 BTU)
himol a air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0M BTU)
Iyisuicfl
❑Yes ❑No NEW RESIDENTIAL MCCII. SQ.FT. P aq B
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand then -
if the building does not currently have a lenmL that it is my respondbility to notify Ne
aecupam f Ne irements which must be met prior to issu ce of Certificate of
Occupwmy. � � t
Ownero uti�agem � � Date TOTAL: ISSUED BY: aVr(_