27346 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'LDINO-LLM MIA, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27346
BUILDING PROJECT'IDFNI'IFICATION
BUILDING ADRE,S ' SANITARY NO. APPLICATIONSUBMITTALDAIE
-D UNIT p LOT p 11..-5 I..•�0"��
P"kRnS�AME PHONE: C CI'OR'S NAME: LICNO: SIC CONTROLg
1 eeoA/ son- Fri
RCHITECr/ENGINEER: LIC NO: A S �� ❑
5_ell�
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT -PLUMB MECII
PERMIT ISSUANCE �, 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ihcrehyafirm
that l am licensed underprovisionsafChaptcr9(commencingwithy0Z Section 0014)dDivisnn3ofthe Rosiness endPrmfessimsCade,colony because is in
PANELS
U❑ andeflec.
< License Clss Lic.p UPT020 AMPZy ' rya
"i<N hate Crime, r 201-1000 AMPS
Z�D'ttZ—�. ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
oz-0
1 understand my plans shall be used as public retards.
F' W SIGNS ELECTRICAL
O4yrn � Licensed Professional
a KU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
S5��OaF 1 hereby affirm that I am exempt from the Contmcmr's License Law for the
41�0
y following reawn.(Sectio,00JL5,Businesa and Rofessimns Code:Any city ormanty TEMP.METER OR POLE INST.
which requires a permit to construct,aha,improve,demolish,or minor any structure
red}�, priormits is...a..al.rtquimathe applicant for such permit m ftlecdgnediummem POWER DEVICES
K<pY that he is licensed pursuant to the provisions of the Contrumrs License Law(Chapter
a^OoLL 9(commencing with Section 7")of Division J of the Business and PofeseloreCode) SWIMMING POOL ELECTRIC VALUATION
'p_y
or he is exempt herefrom and the hasisforthe alleged exemption.Any violation of OIITLFTS-SWITCHES-FlXTURF_S
FZa nSection 4031.5 by any applicant for u
a Permit subjects the applicant o civil penalty of -_
t more than rive hundml dollars(5500).
KQ ❑ I,asowncrnfthe property,ormyemployeeswiN wagau Neirwlecompenso0on, NEW RESIUI'NTIAL ELECf1t _SQ.PT. STORIES TYPECONSTRUCDON
y3� willdo the work,and the suuctum isnot imendedoroffered bristle(Sec.]04h Business
and Profaasions Co ia:71m,Contractors License Law does not apply to an owner of
prnprnywhobuildsorimproves Nereon,endwhodmssuchwmkhimself(inhroughhia OCC.GROUP RES.UNITS
own cmployces,provided that such impmvemmtsummlintendedoroffemdformle.It,
however,the buildingorimpmvement is sold within oneyearadec mpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ La.owncrofthe property,are exdusivelycontncting wiN limnud convuctnrs to QTY. PLUMBING PERMIT FEE Fl.00D ZONE. APN
construct Ne project(Sec.0044,Business and Professions Code:)The Convector's PERMIT ISSUANCE
License Law does not apply to an owner of property w ho bui I ds or improves themoq and
who contracts fmsuch projects with a cmmosch r(sl licensed pursuant othe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
CI an exempt under Sec. ,B&P C for Nis msmat OUTSIDE
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dme DRAINS-Fl.00RROOPAREAGONDRECEIPTM
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby afrinn thatlhaveettnificete of canunuo self-imam,orecmiPicnte of RECEIPTN
Wmken'Cnmpensmion Insurance mecenigedcopy thereof(Sec.TIRE..Lab CJ FIXTURES-PER TRAP which K YN
coven all employee's under this permit GAS-EA.SYSTEM-1 INC. O I s 1
A RECEIPT N
Policy M UtILDING DIVISION FEES
Company GAS-F.A.SYSTEM-OVER (EA) - \ � ' PLAN
4FIYC
❑ Certified copy is hereby furnished.
❑ CenifieJ copy is fled with the city ivpenien division. GREASWINDUSTRLWA$ 1 F.Mii I E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP Dk7E
COMPENSATION INSURANCE
(This action need not be completed ifthe Permit is foram hundred dollars P$100) SEWER-SANITARY-STO EA.2001T. ENERGY FEE
or less.)
I terrify that in the performance of the work for which Chia permit is issued,I shall WATER HEATER W[VEN`UELECfR
not employ any .an in any manner so as m become subject to the Workers' PAID
Compenmtien Lawsnf Cnlifomia. Dam WATER SYSTEMrMEATING Data Receipt#
0 Z Applicant
� 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
V) become subject o the Workers Compensation provisions of the Labor Code,you must
a > fmthwith comply with such provisions or this permit shell be deemed revoked. BUILDING FEE69
W " SEISMIC FEE
(�
CONSTRUCTIONisacomLENDING AGENCY
U z work
aM1y which
this them is amnsvuetion lm,Cis.cency for performance of
O the work for which this permit is issued(Sec.3090,Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name
O PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEC
I rectify that 1 have read this application and state that the above command.is MECHANICAL.FEE
�" a e.I, L agree to comply withall city end countymcbra res andvate laws reducing to PERMIT ISSUANCE
Cn building construction,and hereby authonae representatives ofecus city to intercom,the CONSTRUCTION TAX
L) Z
above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep lIonallso the City of Cupertino against
liebilities,judgments.costa its, whit y in any way mcrueagainst said City AIR HANDLING UNIT(TO IQIXIO CFM)
sz.acm of Ne Booing of pe,nl
/ AIR HANDLING UNIT(OVER 10,1114 CFM)
Sigh pplmtnVCm for Data EXHAUST HOOD(WIDUCD PAID
HAZARDOUS MATERIALS Dom,or handle
HEATING UNIT(TO IWE00 BTU) Date Receiptg
Will the the Coamor Municam ipal ngmcupapal emrenr anddlehuanders lth add Safety HrsAT1NG UNIT(OVER 100,000 BTU) T
cil
sea derived by the Cupmine Municipal Cade,Chapter 9.12,and Ne Health and Safety
Coda,Section 25532(.)4 VENTILATION PAN(SINGLE RCSID)
❑Yea ❑No
BOILER-COMP(3HPOR 114,014B1U) TtS DANCE TE
Will the applica mumu as building by lot Bay Auipmir Qm1v,es Management
�•/ ! D
hagaMuuv air cnmmninants as delved by the Bay A.Air Quality Manegemem BOILER-COMP(OVER 100,000 BTU) NovictP
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. ••ggf�1yy,�
28{719
1 have read the hazardous materials requirements under Chapter 6.95 of the lslry- a
California health&Safety Cade,Sections 25505,25533 and 25534. 1 understand Nat VI f I
ifthe building does not currently have o mount.that it is my responsibility to notify the r LUr
,cacpa r of the rem
quireents which most b,met print to issuance of a Certte ificaof ��/�
Occupancy.
Owner or euthomed agent Data TOTAL: ISSUED BY:
OFFICE