27642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
HUM ; -ELF.CTRI AI. PERMITNO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PLIG PROD-MBCHANIFICA n 7 C /I 2
BUILDING PROJECI'IDF.NTINTCA'I'ION' L o L�
BUILDING ADDRESS: SANITARY SANITARY NO. APPLICATIONSUBMITTALDATE
x/ 1 UIA opa�+///J UNIT# LOT It —
OWN SNAME: PHONE: CONT ACTOR'S ME: N/C CON`TflO•_LX l• J
i6L A/ Z
• A CHITECUEN,I EER: LIC NO: A RH 5:� ,� �/ ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDENTIAL JOB DESCRIPTION
m ezz Ihereby affirm that l am licensed underprovisions of Chapter9(commencing with
POO Settie.7000)of Division 3ofthe Business and Professions Cale.and my license is in PANELS Q)FIPI
Mfull force and effect. / 7 '/ wJl2 UP TO 200AMA
M
License Class Lac.p ((Z� 47.7 7
rn=y Oam Contactn, 201-I" PS
z ARCHITECTS DECLARATION OVER 19M AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
O Z_p I understand my plans shall be usM as public tecomds.
� �� Licensed Professional
SIG EEC KCAL
NK OWNER-BUILDER DECLARATION PECIAL CIRCUIT/MISC.
NOV I hereby from that 1 am exempt from the Comtrecom's License Lsw for the
3ktan followingran.eno.(Secdnn 7031.5.Businessund professions CMe:Any citymcaunty TEMP.METERO 1,11 INS'
(:of Vs J which requires a permmct
it to construct,alter,improve,dcot sh,or repair any am
N>,$ priunoitsissnance,also rcyuimn the nppliamt for such petmiun file usigned Hato ant POWER D^
4O,z that he is licensed pursuant to the provisiom mthe Contractors Lice ve Inw(ehapter
6oLL 9(commencing with Section l00(Oof Division 3nf theBminess end Rofes ons Cade) SWIMMI OLI?L 'RI� VALUATION
ty_,& or that he is exempt thertlrom anJ the loxia far the allcgM exemption.Myi per ion of OUTL 5 WITCH - URP.S
F. a 5ection]03I.S by any epplacam finepemtit suhjens the applicunnoucavi}\p\pcAntehy of
W mno,more than Be,hundred dollars(5500). ,SIDE 1 LISCTR S .PT.
❑ 1,asownnoftheprnpcny,nrmyemployees with walecana heirsolecom smion, Q STORIES TYPE CONSTRUCTION
qR_ will do the work,and the amcturtisnm immnJMoroffered for:ale(S,r.7M,Bu' ea
and Professions Code:The Commner s License Low does not apply m an owner
pmpeny who M1uildrnrimprove thereon.and whodoes such wnhhimalfor throughhis
own employees,pr..idedthat such improvements am netintended.,offered for sale,If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold withinone yearof completion,the owner.
under will have the burden of that he did not build.rim rave far sof TOTAL'
pmvin0 p Tomas
sale.).
❑ I,mowncrofthepropcny.umexdusivelyconuactingwithlicenaed conuannrs to QTY. PI,UMBI PERMIT FEE FLOOD ZONE. APN
omtruct the project(Sec.7004,Business and Professions Cade:)The Cnntroctora PERM ISSUANCE.
Lieense lawdoes not applytoenawnerofpropcny wh.builds orimprovesthermn,wd A
a
whoenoms for such projects with acnnuacmr(s)licensed pursuant to the Coatrectors ALTER VENT.WATER(EA
License Law. ) FEE SUMMARY
❑ I mm exempt under Sec. ,R&P C for this reason BACK FLOW PROTECT.DEVICE IDE FEES
SANITARY Y N
• Owner Dam RECEIPT'p
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPIiNSA'f10NDECLARATION SCHOOLTAX Y N
❑ erereby Comperrsmthnt I b come oraecmenf mnsennoaelbinsurgnr Lab C.)which FIXTURES-PER TRAP RECEIPI'p
Workers Campensmian lwurence oreccnified copy,thermf(Sec.3g00,lab C.)which PARK FEE YN
covers all employee's under this permit, GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT'X
Policy X BUILDING DIVISION FEES
Company GAS-EA,SYSTEM-OVER 4(FA) PIANCHECK FEE
❑ CemtifiMcopyisherrbyfumished.
❑ CcnifieA rgpy is file)wird the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMI?ION ROM WORKERS' GRFASIiTRAP SOILS PEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is fours hundred dollues,EJ10) SEWER-SANITARY-STORM PA.200FT. ENERGY PEI?
or lcsuJ
I certify that in the performance of the work far which this permit is issued,Ishall WATER HEATER WNP.NT/ELECIR
not employ any person in any manner so as to became subject to the Workers PAID
CnmperumionlnwsdCaliferia. Date WATER SYSTRM/BEATING pia ReeeiptX
O 7-. Applicant
2 O NOTICE TO APPLICANT:If,after making this Certificate of Esomption,you should NEW RESIDENTIAL PLMIL SQ,TT. TOTAL:
rV) become subject to(lie Worker's Compensation provisions ofthe Labor Code,you must
LYi > forthwith comply with such provisiomor this permit shall be deemM revoked. BUILDING FEE
wz CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 Ihercbyoffirm door hem isuwnsuuaion lwdingagemy forthe puicommovof TA - ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
V. Lr Lcndcr's Name PLUMBING FEE
Q U Lender's Address QTY. MECHANICAL PI7RMIT FEE
I certify thus 1 have mud this i pevenoon and state @at the above infnrmutic n as
correct I agree mcomply with all city and county ordinances and stale laws relating to PERMIT ISSUANCE MECHANICAL FEE
�y' y haddangmmwcdon.and herebyautharize repreanlmavesofilds city tormerupon tha CONSTRUCTION TAX
1..) Z am
bove- entaoned ppurpose.property for inspection purp . ALTER OR ADD TO MECII.
(We)agree to Hove,indemnify and keep harmless the City of Columnar,against
Liabilities,judgntents,cosaaadepenseswhich may inan wayaccrueagalnmand City AIR HANDLING UNIT(TO 10.000 CFM)
in uenc he granting Ofther,
AIR HANDLING UNIT(OVER 10,01111 CFM)
Si marc of ApplicanUCont Data EXHAUSTHOOD(W/DUC`f)
PAID
IIA RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt X
Will the applicant or future building occupant Borc to handle hazmdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNI'I'(OVER 100,11IX1 BTUI TOTAL:
Code,Section 25532(x)? f1l�yd pp
11 yes 13 No VENTILATION PAN(SINGLE RESID) P A 9
Will the opplicamarder.huilding by the useeyuipmir Quality
Management
BOILER-COMP(3HP OR 100,I)IM BTU) ISSUANCE DATE
• harardous air comamitunts ns de(nM by the Bey Ates Air Quelity Mmmgement BOILER-CDMP(QYIiR 100,00(IBTU)
JAN � 91995
District?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.pT. CI1 Y Uh
uurEH fINO
1 have read the Safety
Coma,de,
Sections 5505requ,25533 under Chapter untrained
of the that
if
uil Ing do&Safety CMe,Sections leaned.
that
h,t it is y responsibility 25534. I understand that
of thehualof duesnutcurrently have atenant,thatitar myrincefto notify the
Occupant of the requirements which mon be met prior to issuance of a Cenifiwte of
Occupwcy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFIC