27688 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER PINO
BUIL ;N -ELEC'TRI AL PERMIT NO.
CAL
BUIIAINC DIVISION APPLICATION/PERMIT PING PRNG-MFICHANIFICA 27688_C O O
BUILDING PROJF.(TI'IUEN•1'IPICA'I'ION I v o 0
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMDTAI.DATE
aUNITLOlM *A
OWNERS NAME: HO :.
NTRACI'OR'SNA E: LIC NO: N/C CONTROL®
Y�t
•AR 1'1 iG /ENGINEEGLR O: A)OHF. S: .❑
CONTACI': PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT IEE
BLDG ELECT PLUMB MECII
PERMD'ISSUANC13 ❑ ❑ 1� ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �YyL JOB p`SCRII/TION
Q 00 I hcrcby affms that l um licensed..ras m rvisions imis Co¢r9(c0 mmecense with _,frLV♦\-!4`�s JTn/.
tui;10{0. Section full force and effUivision3 of the Business end Professions Code,and my license is in PANELS
V
ttFzW LicenseC Lic.M UPT0200AMPS
on 1 HITECPS�I.AR TIO 2(11-IIMMI AMPS SQ.PL FLOOR AREA $/SQ.IT.
770� 1 understand my plain sM1all bo used¢s public recnNa. OVER 1000 AMPS
P'45; SIGNS ELECTRICAL
9 1Licensed lbufessional
yd'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
i6t�dU I hereby ntfi.that I am exempt from the Costmeniev License Law for the
W3[i rFq lolinwing reason.(Smtimn 7(13L5,Buainesr anA Professiane Cwle:Any city nr county TEMP.METER OR TALE INS T.
which reyuires a permit to construct,alter,improve,demolish,or repair any structure
� i•� prior ns its issuance.also rtyuirts the applicant for inch penniuo fixe signed sm¢ment POWER DEVICES
41 Op that he is licensed pu,,amra othe provisions of the Cortmeme.License Law(Chapmr
aX ca 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING1'001 E 1' VALUATION
W�v1 or that be is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETSSWITCl11S-SWITCHES4
F ¢ Sion 7031.5 by any applicant for a permm -
it subjects the applicant o civil penalty of , p p •--• r;+
not morcthm Ove hundrel Jollars(S500). y
tY lam- props y,ormyemployeeswiNwagcsastheirsolecompensatim. NEW RESIDENTI L IR In SQ.FII
❑ hmownernOhe n STORIES 'TYPE CONST RUCTION
will do the work,and the structure is not imendMoroffertd for safe(Sec.'/OWi.Business
and Procanions Gale:The Contractors License Law does not apply m an owner of _
property who builds or improves thereon,and who does such work himsclfor through his -� oCC.GROUT' NIS.UNITS
wnemployeea,p ovidedthatsuchimpmvememaarenoti tendedorufferedforsule.If,
however,the building or improvement is sold within one year of completion,the owner. TOTAL:
budder will have the harden ofmoving that he did not build or improve for purposcol'
sale.).
❑ 1,mownerofthepropeny,amexcw.vivdycontractingwithlicensedcontmcmrsto QTY. PLUMBING PERMIT IEE FI.O ZONE APN
1'instant the project(Sea.70HI,Buviness and Professions Code:)The Contractor's'
ittnsc lewd«snot applymannwncrof property who builds orimprovestherconLand PERMITISSUANCE
who contracts forsuch projects withacornmetor(s)licensed pursuant to the Connactars ALTER License Law. (E-A) FEE SUMMARY
❑ nm exempt corder Sec. ,H&1'C for Ihix rensan BACK FLOW PR0'1'ECT,DEVICE OU'I'SIDI:PhIS
Owner Dan
SANITARY Y N
RF,CEIPTN
DRAINS-FLOOR,ROOF,AHEA,COND.
WORKMAN COMPHNSATIONDECLARA'1'ION SCHOOLTAX Y_N
❑ em'Co affrmthat lhave acenicenle ifi roUihe f(Sn.rq0,Lab
C.)whiof REQiIPI'ta
Weekend CompensationlnsumnceoracenifiW copy theremf(Sec.Jg00,Lab CJ which FIXTURES-PER'TRAP PARK FEE YN
c.overs.11 employee's under this permit. GAS-F.A.SYSTEM-1 INC. OUTLETS RECEIVE'N
Policy W BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(IiA) PLANCHECK FEE
❑ Cenifed copy is hereby furnished.
❑ CcnlfieA copy is fled w'nh Nc city impectinn division. GREASE;/INDUS'I'RLWASTEINTERCHp OR GRADING PHE
CERTIFICATE OF EXIIION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectimmmeedmot be completed ifthe pcmtit is forms,hundred dollars(SIW) SEWER-SANITARY-S'T'ORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VEN`DELECTR
not employ,my person is any rammer so as to became subject to the Workers' PAID
Compensation Lawsof Culifomia. Data WATER SYSTEIMTREATING
Date ReceiptM
z Applicant
0. NOTICE T'O APPLICANT:Fidler making this Certificmeof Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL:
(n become subject n the Worker's Compensation provisions of the Labor Code.you must
a forthwith comply with such provisions or this permit shall the deemed revoked. BUILDING FEE
Q CONSTRUC PION LENDING AGENCY SEI SMIC FEE
z 1 hereby affirm Hnnhere is a ex nstionamn lending agency for the performance of
U O the work for which This permit is issued(Six.NEG.Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
w0 F Lenders Address QT-Y. MECHANICAL PERMIT IEE
PLUMBING FEEU I certify that I have read this application and same that the above information is
�" a agree to coin with all cit and ordinances and state laws relatin m PERMITISSUANCF. MECHANICAL FEE
correct.la
B comply wi city county g
UZbaidingc0mmdpro,andhcrebyauthorizerepses. uvea of this city to comeupon the CONSTRUCTIONTAX
U z aboveWc)aonedpropcnyfor inspection keep ma. ALTER OR ADD TO MECI I.
(We)agree to sa ,indemnify and keep harmless the Ciry.of Cupen'la again t
liabil" its ostsand ex r swhlch inn in any way accrucuga st suit y AIR HANDLING UNIT RO 10.000 CFM)
an no e r mramspa ms
AIR HANDLING UNIT(OVER I0,01)CFM)
do
Stgnmum of ppllcant/ConliWaRr. m EXHAUST 11001)(W/DUCT) PAID
I IAZARDOUS MATERIALS DISCLOSURE. IIEATING UNIT(TO 100.00 BTUI Date Receipt#
Will the applicant or PIn
ine buildm an some or handlnei,, dolls nmtcrial IIEATING DNIT(DVER IIXI,000 BTU
as defined by the Cupertino Munn ode,Chapin 9.12,and the Health and gafcry ) T
Code,Section 25532N)1 VENTILATION FAN(SINGLE RESID) \
❑Yes ����NNNN
BOILER-COMP(3HP OR IOO,Wo BTU) ISSUANCE DATE
Will rheapplicamorfuwrebuildingaecupantuseequipmessnrdeviceswhichemit
-�.hrecdaus air commotion,as de0nerl by the Hoy Area Air Quality Management BOILER-COMP(OVER KIM BTU) PAID
D...Hr l
❑Yes ❑No NEW NCSIDENTIAI.MECII. SQ.FT. �
I have read the hazfelt'Code,
materials 5505.25533 under Chapter ersi of the pV (j 1994
California have
Health&Safety Coda mattcria 25505.earth and 25534. I ter 6.9 nn f ohm V
ifthe building dtws not currently have a tenant,that it is my responsibility to notify the C/�
occupant of the requirements which must be met prior m Issuance of a Certificate of ()/- LI/
Occupancy. ..
Owner or amhonmJ agent Date - TOTAL: ISSUED BY: -
OFFICE