27268 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING ELECT AL
CITY OF CUPEPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 27268
B LDING ADDRESS:
Q SANITARY NO. APPLICATION SUBMITTAL DATF.
7.r UNIT# LOT#
:RS NA E: PHONE: NTRACTOR'S NAME: LIC
N/CPIN 66
CONTROL#
•ARCHITECT NGINEER: WC NO: DDRESS: W#a�Ar S.- ❑
CONTACT. PHONE:
A610 QTY. ELECTRIC PERMIT FEEBUILDING PERMIT INFO
—w/jj��/ 7 PERMIT ISSUANCE BLDG ELECT PLUMB MECH
C` s
LICENSED CONTRACTOR'S DECLARATION APPLIANCES RESIDENTIAL
1 y00 Ihereby 7000).frmthatTam of
Bu inns and isionsass,Code.
(commencing nse with
�ai100�+ Sermon force and e f Division J of the Business and Professions Cade,and my license is in PANELS
aZ,
full
Lwvme Clnd effect.
yQLL Datense Cl ass Contractor UP T0200 AMPS.
ARCHITECT'S DECLARATION 201-1000 AMPS
ZOhQ OVER IWO AMPS SQ.PT.FLOOR AREA $/SQ.FT.
O Z..ul I understand my plans shall he used as public records.
<"� SIGNS ELECTRICAL
�P�Cja OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ��
u�3LLF' I hereby affirm that I am from'be frothe Contractors License Law for the
O G following reason.(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST.ie. which requires a permit 10 construct,alter,improve,demolish,or repair any srcucturc
5a2 pdorritsiseuance,alssorequires the applicant forsuch permit to file aligned statement POWER DEVICES
a a O p that he is licensed monsoon to the provisions of the Contractor's License Law(Chapter
xo 9(Commencing with Section]000)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
µ)_y or that he is exempt therefrom and the basis for the alleged exemption.My violadonof O
Y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500).
❑ basorust.fthepr.penmply,ormyeoyeeswithwagesasthsirsolIo mpensation, NEW RESIOENTIALMECfR _SQ.FT. STORIES TYPE CONSTRUCTION
a,3� will do the work,and thesmsnure is not inrmdedoreffered fors c.7044,Business
and Professions Cade:The Contracrr's License Lawsit uit at apply to an owner of
Poiramywhobuildsminatim..there hworkhimeelforthmughhis
-weemployese,pavided NarsucM1' provememsare notimendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building orimprove em is sold withinaneyearofc.mple'on,theowner-
builder will have the burden of pr ming that he did not build or r purpose of
salede
❑ I,asowoeroflheproperty, exchaivdyconoactingwith otmcmrsto QTY' PLUMBING PERMIT FEE FLOOD ZONE ppry
construct the project(Sec.70dL a ess and Probes'o ode The Contra yor's
LicemcL.wdaesnotapplyroanow rtof,. wh a nmproves there d,' it PE IT ISSUANCE
whocontmms for such projects with a number. 1 e ed ursusntmthe�nr rs
License Law. / H re A R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. B �pr theeso
ACK FLOW PROTECT.DEVICE UTSID- ES
Owner D4* SANITARY Y N
WORKMANCOMPE ATIONDICi TION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
�A SCHOOLTAX Y N
❑ 1 hereby affirm that I have a certifcat of cansem m Ifff-insure,ora eertifie too FIXTURES.PER TRAP � RECEIPT#
Worker%Cnmpenseti.n Insurance ora cern edcapyrhereof(Sec.38�C.)which PARK FEE Y N
avers all employa's under this permit
Policy# GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Company BUILDING DIVISION FEES
❑ Cenifedcopyishenhyfumished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is fled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.200PT.
or ENERGY FEE
less.)
Icertify that in the performance of the work for which this permitis issued,lsball WATER HEATER W/VENT/ELECR
ma employ any person in any manner so as t.become subject to the Workers' PAID
Q zCompensation Laws of California. Date WATER SYSTEM/I'REATING
Applicant Dare Receipt#
'z NOTICE TO APPLICANT:If after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. 'SQ.FT.
r+ UO become subject o the Worker's Compensation provisions of the Labor Code,you must TOTAL:
forthwith comply with such provisions or this permit shall be,deemed revoked. BUILDING FEE
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a consuuction lending agency for the performance of
U 0 the we&for which this permit is issued(Sita 5099,Civ.CJ T ELECTRIC FEE
fY H Lender's Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �.
1 cI agrifyee
that 1 have read this city
and county
and star Ices an above immersion reladoa ie
�^ a
correct.legree to comply with all city and county ordinances and star laws relating to PERMIT ISSUANCE 'MECHANICAL FEE
r7q building construction,and hereby inflation representatives of this city to enter upon the
V r1- above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save indemni ke p harmless Na City of Cu stun against
ImIalitiMpargments, xpenses ichmayinanywayacerueeainsrsaid City AIR HANDLING UNIT(TO 10,000CFNE
in en nee ingofthispe it r .
AIR HANDLING UNIT(OVER 10,000 CFM '
Signatureof Aplin nUC Date EXHAUST HOOD(W/DUCf) _
PAID
HAZA US MATERIALSgoweapntDISCLOSURE HEATING UNIT(TO I OO,OOD BTU) Date Receipt#
Will the applicant or future building de.Cap erre or handle hazardous materiel
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 W,000 pill) - A
Code.Section 25532(a)v
11 Yes ON. VENTILATION PAN(SINGLE RESIO)
BOILER-COMP ISSUANC AT
Will rain co applicant ants as defined by the
lay Area Air Quality
Managemes which ent
it (3Hp OR 100,000 BT11) Ip
® �
• hazardous air conwminants as defined by the Bey Area Air Quality Manegemrn[ BOILER-COMP(OVER 1110,000 BM) Y r'
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have read the hazardous materials requirements under Chapter 6.95 of the - NOV -81994'
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
ifthe bntof gdcesnmments,which y have a
Ise that itismy rsuanceoilityrnficat the VVf CM S
occupant of the requirements which must be met prior r issuance of a Certificate of CITY Ur
Occupancy.
Owner or authorized agent Date T T ISSUED HY:
OFFICE