27841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONrii •- PERMIT no.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTIDENTICAL
FIC
BUILDING PROJECT IDENTIFICATION 27841
BUILDING ADDRESS: SANITARY NO. "Mill AT IONSUBMIITTT��3ALDATE
Q( � � UNITk � LOT# / / '1�7�.�
OW S,N MF.:TI PHON CONTRACTOR'S AME: LIC NO: )-
a/ oM PHA
/_ //1M er NEC CONTROL is
•ARCIIITECT/ENGINEER: LIC O: J'CWV ADDRESS: O
CONTACT: PHONE:
//�) '(�j QTY. ELECTRIC PERMIT FEE BUILDING PERMiT INFO
4ee Ly err Q �_'6D / PERMIT ISSUANCE RL} ELECT PL MEC}I
Rr
LICENSE ONTRACTOR'S DEC ARATION APPLIANCES-RESIDENTIAL 4rQ� X
qyz Iherehy affirm that l am licensed underpowdoonsof Chapter9(commencingesim TOB DESCRIPTION
2.00Seniorr,)of DivisionJmf me Business and ProfessionsCWe,and my license is in PANELS
<u,i fall force smderfert.
IQ„ZW License Class Lic.M UP T0200AMPS
rn t a
Data Contractor 201-1000 AMPS
20y Z, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA l;/SQ.FT.
O'z'-' I understand my plans shall be used as public records.
r Y SIGNS ELECTRICAL /
Licensed Professional
'Ce OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°�IOaU I hereby affirm that 1 wo exempt from the Contradots License Law for the
W 3 f+-uusas
s following reason.(Section 7031.5,Business and Forbad ons Code:Any city or county TEMP.METER OR POLE INST.
which rewnres u permit m consumer,aIle.improve,demolish,or repair any sumaure / J
}� prior to its issuance,aisorequires the applicant for such permit to file a signed smmment POWER DEVICES
W 0 Fe
mat he is licensed i uraCommandoesm to the provisions of 1,Commandoes License Law(Chapter
Fe
d 9(c.mmencin,with Seeded 9000).[Dlvlsi.n 3ofine Business and Professimns Cade) SWIMMING POOL ELECTRIC VALUATION
or thatSectio 7isexempt 1.1byaberefromand mepenbasis for mealleged exemption.Any ivilPearimyof OUTLETS-SWITCHES-FIXTURES qy 603.-
2 Section703thI 1.1byanyapplicant forapermit subjects the epplicemmecivil Penalty of
0 not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
m ❑ solo w,k,.rd epropeny,ormyemylndedor ffeaddsasrheirsm.7044,Bsiness
will dmhewons ande:The Cureisnotimm�dedm ofwdoes nota(SceJM4,Business
and Professions Code:The Contractor's License Lew docs not apply to Its owner of
property who builds orimprovesthereon,and whmdcessuchwark hi,nselforthrough hf, OCC.GROUP RES.UNITS
employees,pingo,imarve imt nVold ithin nm imendedrapietiorisw If,
harder ,will hhe ave
burden of einem lshe,he ids.,me yew of completion,me owner- TOTAL: 170
builder will have the burden of proving met he did nor build or improve for purpose of
sale.).
❑ QTY, PLUMBING PERMIT FEE FLO ZONE APN
hueowner ofthepropeny,am exclusively contracting with licensedcontractors to
consumer the project(Sec.7044,Business and Professions Code:)The Contractor's
License LawdoesnotapplYtounownerofpropenywhobuildsorimprovesthereogand PERMIT ISSUANCE
whocormacts forsuoh poweerswith.comradmoi)licensed pursuant to me Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) ESUMMARY
❑ 1 am exempt under SIC. ,B&P C for this mason F
BACK FLOW PROTECT.DEVICE SANITARY N
Owner Date R ,PT it
DRAINS-ROOK,ROOF,AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers'CoyaffrmthaIlhave a rance iifeme odleWy themonfled.3e,0,LabCfc m.fwhich
FIXTURES-PER TRAP RECEIPI'M
Workers'Cmmpeyea,i.nier this Permit,
fiedcopy thereof(Sec.3g00,Lab CJ which PARK FEE Y N
covers all employee's under permit REC
GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK PEE
❑ Cenified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASMISDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need mare completed ifthe permit is(armor hundred dollere($I00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of me work for which this permit is issued,I shall WATER HEATER W/VENT/ELECR
not employ any person in any m as m become subject to me Watkins' PAID
Compensmiou Lawsof Califomis. Dam so WATER SYSTEM/TREATING Date Receipt.
Z ONOTICE TO APPLICANT:If,atter making TAC:
this Cerificme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
z . becomesubject comply with
it Workers Coons or tision provisions shot be the Labor Cada you must
a ; forthwith wmply with such provisions or this permit shall be deemed revoked. BUILDING FEE
L2a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE S+
z I hereby affrn that hem is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Co.C.) TOTAL: /7O ECIRIC FE O O O k$'-•'
Lenders Name O
40 U Lenders Add.. QTY. MECHANICAL PERMIT FEE PLUNKING FE
I certify that 1 have mad this application and state that the above information is MECHANICAL FE O S
correct Ingres to wmply with all city and county ordinances end seam lewsrelatingm
Ori building consrmPERMIT ISSUANCEction,and hereby authorize representatives ofthis city to enter upon the CONSIRUCTIONT
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
.^� (WC)agree to save,indemnify and keep harmless the City of Cupertino against
him Iti/esJ,jfu�'d-f'e'"°'ent.costs and expemes which may in any wayac�rneyagatinst said City AIR HANDLING UNIT(TO 10,000 CFM)
in conse'iJJaf�-f he g.a g of lisp Wit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sirstore of ApplicanUContreaor Date EXHAUST HOOD(WMUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,1100 BTU) TOTAL:
as defined by the Caperton Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Sectionx)? VENTILATION FAN(SING LE RPSID) O
0 ye, 11 No Yes
ISSUANCE DATE
Will the acontammfts as building by
Bay Area
Quality Management
BOILF,R-COMP CHP OR 100,000 BTU) P A I
hazardous air contaminants as defined by the Bay Aree Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District?
❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FT. APR
2
T have red the hazardous materials od,mmmeots under Chapter 6.95 of the ����
California Health&Safety Code,Sections 25505,25533 end 25534.1 understand that
if he loin,docs not currently have a mnunkthat it is my responsibility to ratify me CIIY ser CUr'E
occupant of it ray^ mems which mus,he met prior to issu ace of a Certificate of
Occupancy J /J��/�
Owner or morized.gem Dam TOTAL: 70, ISSUED BY:
OFFICE