27078 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPD,RTINO -
BUIL DIN -E ECTR[ AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM ROJEGFEDENTIFIC 27048 7 O 4 Q,
BUIWINGPHOJECI'IDENTIFICATWN L O
AU,LL/[DING AD RESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
r/' � . UNIT# LOT l o n
OW S NAME: PHOy _J ql O R' NAME: LI N/C CONTROL t "�
R CP/ENGIN E : - LIC NO: /V NI AD S: /-Y_ / ❑ 1
ON T: PHONE: �,OvIYJ•L-_"�
^� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
U (�{�V(/ BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL TOA DESCRIPTION
pyZ I hereby affirmthat l am licensed underprovisions of Chaplw9(commencing with
00 Section]WO)of ]pf the Business an f S ons Cape,and my license is in PANELS
full force node c tsion 5L'1/O_/p_ UPT0200AMPg
6z Licenx Clan Lia q
ti6y
are Comrama, 17 12 201-IUdDAMPS
z �'b ARCHITECTS DECLS DECL A OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ^ 'I undemmnd my plans shall be used as public records. •
SIGNS ELECTRICAL
Licensed Professional
N OWNER-BUILDER m the CoATION SPECIAL CIRCUIT/MISC.
4xOCIA I hereby affirm that 1 am exempt from the Contractors License Law for the
W CIA following reason.(Section con L5,Business and Professions Code:Any city or countyuctow TEMP.METER OR POLB INST.
f�>-¢ which iia is s n permit re canes the aper,improve,demolish,or gash any structure
rnY0 that hoits issuance,also requires thevisio s of the
he Co permit's Lfile ice signed statement POWER DEVICES
raj O thatheis licensedPursuantemnrto the)of Provisions of thethe Contractor's License Law(Clouser
aWM� 9(commencing hisxemitthreiromand)oebasision3oftheedexess and tion.AyviolaCode) SWIMMING POOLELECTRIC VALUATION
tr)Mm Or Socti heisex by therefrom and the permit subjects thedexemant to civil Penalty
of OUTLETS-SWITCHES-FIXTURES
4 Secti methan5 by hmy undred
dollars($500). subjects the epplicannoacivil penelry of
mnot morethanfivehundreddoliors yemp. NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ Lthewrk,andeproperty,ormyemployeeswilheregesastleirsde compensation,
^y will dothewons andthe eoContisnor',License Law
wdoesed not
Dan Business
and Professions Cade:The ves Contractor',License Law does oat apply m as owner of
p4cqownercywyces,dvir thatschimpmvemenB notihnde hirofffdforule.his OCC.GROUP .RES.UNITS
ownewever,thees,providWtprovehimprovementhin ne exec compffered theroe.If,
Zilder gillhavl the burden of proving thasolt
he did act
eyew of improve foron.theowne f TOTAL:
builder will have the burden of proving that he did nor build or improve far purpose of
sale.).
Las uwnerof the property,am exclusively convecting with licenxdcantrecmrsm QTY. PLUMBING PERMIT FIiB FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors -
LicenseLawdoespot apply to an ownerofproperty whobuilds orimprovesthereon,and PERMITISSUANCE
whocontracts for such projects with acontracmr(s)licensed purmanOothe Contractor's ALTER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDEFFiffs
SANITARY Y N
Ow r' Date - RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIOND Wself-TION SCHOOL TAX Y N
Thereby affil wilwar acertifcateofcomxmcavd(Snsure,o,LabC.)cedifictue ofwhich XTURES-PER TRAP RECEIPT#
�, orSA
' 'on lnsu{�y YPy�ifiedcopy Nereof(Sec.3B00,Lab C.)which PARK FEE YN
coved�i�fi)16Iri/I RBCHIPT#
Poliid/ 7/ V � h � BUILDING DIVISION FEES
ComGA `-HASYSTEM-OVER4(EA) PLANCHECK FEE
❑ hereby u ad. "❑ filed with th city inspection division. GRE(SFJINDUSTRG W TBI RCE ' 1__
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA E SOILS FEE
COMPENSATION INSURANCE
(This sectioineed notbe completed ifthe permit is forone hundred dollars($100) SEWER=SANITARY.STORM EA,20OFT. ENERGY FEE
In Ices.)
I cenify that in the performance of the work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ,any person in any m o as to become subject to the Workers PAID
Compensation Lawsof Coliforal, Date a WATER SYSTEM/TREATING Date Receipt#
Oz Applicant
Z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
E-' to become Subject..he Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
W A CONSTRUCTION LENDING AGENCY - SEISMIC FEE
z I hereby of ion that there is a construction lending agency for the performance of
O rhe work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
p-v lenders Name PLUMBING FEE
O U Lenders Address QTY. MECHANICAL PERMIT FEE
•�, 1 cenify,thot 1 have reed this application and store thin the above information is
C a correct.lagre r comply with all city and county ordinances and state laws relating to PERMITISSUANCE vam� MECHANICAL FEE
�+ building cons u tion,and hereby amhorizerepresentafivee ofthiacirymemerupon the CONSTRUCTION TAX
U z above-mens rte pro arty for inspection purposes. ALTER OR ADD TO MECH.
(We) gra ,indemnify and keep harmless the City of CupeZCnals,'dg t to and expenseswhich may in any way accrve ity AIR HANDLING UNIT(TO IO,OOD CFM)
conm4 n t at an
of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signetureo cmVCom or Dem EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO IOg000 BTU) I ,Date Receipt#
Will the applicant or future building occupant store or handle havnrdoos material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)4
EI Yes No
VENTILATION FAN(SINGLE RESID)
❑
Will theapplitarfuwrebuildingoccopant use equipmnt
eordeviceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ^t 'ISSUANCE DATE
wn
msNous air contaminanls as defined by the Bay Area Air Quality Management BOILER-COME(OVER Iffl,"BTU)
bdG? ❑ OCT. 18 1994
Yes ❑No NEW RESIDENTIAL MECH.-SQ FT.
I have read he hazardous materials requirements coder Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that e'r I Uf• 1,riJI-LISI IINU
occupantoffthe building doesnoements which ust Imt,thato is myssuanc sibilitymnmiOf lr
occupant of the es not c currently
which mint be met prior m issuance of it Certificatenotify
he
Occupancy.
Owner or authmired agent - Date TOTAL: ISSUED BY:
OFFICE