27721 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R11I1' 87G'=RLECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL �I A
BUILDING DIVISION BUILDING PROJECT IDEM'IFICAI'1(IN I L
BUILDING SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT
O -RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:seggg
NIC CONTROL#
L
RC ITECMNGINEER, LIC NO: ADDRESS ❑
ONTACT: PHONE:
QTY.;j� S ELECTRIC PERMIT FEE BUILDING PERMIT INFO
'µ '^ - t^'— BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, JOB DESCRIPTION
moez I hereby affirm that l w licensed under provisions of Chapter 9(commencing with
woo C Section 7")of Division 3 of dte Business and Rofesaions Cde.andmylicenscism ppNEl$
RdE fu 11 fmceand eff PANEL UP TO 201)AMPS
FZW Data I-JR—TU �
sn 4 Data Contractor EQ..- 4T�4 201-1008 AMPS
Z Oyu ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z I understand my plans shall be used as public records.
�'. SIGNS ELECTRICAL
QYn Licensed Profeastaxed
gC U OWNER-BUILDER DECLARATION SPECW,CIRCUrlYMISC.
KOaW
1 hereby affrrn that 1 am exempt from the Contractors License Law for the
atso¢, following worm.(Sectim 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
0.n which requires.permit m construct,alter,improve,dcnmlim.or repdr any mucture
EY 7 imsemits isxuance,nlsurequ'ves the applicant for such permitm file eaigncdsunemenr POWER DEVICES
p' p that he is licensed pursuant m the provisions of the Contractees License Law(Chapter
a60�G 9 commencin SWIMMING POOL ELECTRIC
X0 ( gwith Section DiviaionJ.fthe Business and Rvfessiore Code) VALUATION
or that he is exempt herefrom and the basis for alleged exemption.Any violation of Ol1TLETS-SWITCHES-FI%TURE$
t— 6 Secrion]07L5 by any applicant forepcmtir subjects the applicuntmecivil penJty of
t mnrethan Ise"I ndreddollars($500), NEWRESIDENTIALELECIR —SQ.
C n❑ I,mowneroftheMMp .ormyemployeeswithwagams irwlecompenssfion, STORIES TYPE CONSTRUCTION
willdo rhe work,and the structure isnot intended oroffered forsale(Scc.7044,Business
and Professions Code:The Contractors License Law does not apply to m owner of
Property whobuildsorimproves thereon,wdwhodoes such workhimaelforthroughhie
ddthmsuchim OCC GROUP RES.UNITS
awncmployen,provi provementsare not inmndedoroffered forsole.If,
however.the building or improvement is sold within one yemofcompletion,theowner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lasownernfthepropcny,umexclusivelycontradngwithlicensdconvactorsto QTY' , PLUMBING PERMIT FEE FLOOD ZONE APN
comtruct the Project(Sec.7044,Business and Professims Code:)The Contractor's
License Low does not appy to an ownerofpropeny wholoolds orimpr.ves thereon,and PERMIT ISSUANCE
who cmmwetsfar such projectswitha mraracmr(s)licensed pursuanuo the Comacuse, IN
GR
ALTER- A &VP.NT-WATER(G)
License Low. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this maven BACK FLOW PROTECT.DEVICE SID.F S
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Iherebyuffirm that l have a cerifcuroofconsent to sdGimme.ors certificate of FIXTURES-PER TRAP RECEIPT#
ork.'Compereadon Insurance.,a certiftdc.py thcrtof(Sec.3800.Lab C.)which PARK FEE Y N
cov
en all erov[tve rthioeyniA O y BUILDING DIVISION FEES
Policy# TSI LK7(O GAS-EA.SYSTEM-I INC.4 OUTLETS
Ej- env � —$ (�I GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
eniEd copy is hereby fumishd.
❑ Cenified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This onedovoeed not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM FA.200IFT. ENERGY FEE
orless.)
Icerrify thein the pcKommnce of the wmkforwhich thispermit isismxi.[shall WATER HEATERWENT/ELELTR _
not employ any Person in any manner so m m become subject to the Workers' PAID
Compeneation Lawsof California. Dare WATER SYSTEM(fREATING Dole Receipt#
O (z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Fwaniyou should NEW RESIDENTIAL PLMB. SQ.PI'.
tion TOTAL:
C7 In becomeeubjecr m the Worker's Compensation Provisions of the Leben Code,you most
forthwith comply with such Provisions or this permit she]he deemed revoked. BUILDING FEE _
D.7 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
OI hereby amrm that thve u a camwd.n lending agency for the perfomtana of TOTAL JJU ELECTRIC FEE
the work for which this perwit is issued(Sec.3097,Civ.C.)
Lowlers Name
4s. PLUMBING FEE
Lender's Add — QTY,;R' '-'.MECHANICAL PERMIT FEE
LJ-1I terrify that 1 have wall this application and state
that the move information is - MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and sorsa laws mlvting to PERMIT ISSUANCE
DO buildingeomtmction,and hereby authorizerepresentames ofthis city tomaer uponthe CONSTRUCTION TAX
Z above-mentioned Property for inspmtion purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keap harmless the City of Cupertino against
Ii.b.fifies,p5litmov,costemalsspensa which may many way amnia against said City AIR HANDLING UNIT(1'010,0(1)CFM)
in couqu ce a gru�Bm f r.
t I�/ AIR HANDLING UNIT(OVER 10,1100 CFM)
ZShy mof upb ontrac r Dam EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MATERIALS e DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dare Receipt#
Will the applicantor Tatum building assumes Chaptlow er 9.12,
handle Health anmmeoel HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined a the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Sceo0 25532(a)] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will me uppl'mantorfmurebuildingoecupantusc equipmemmdevicee which emit BORER-COMP(JHPOR 100,000 BTU)
homrdous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER IM."BTU)
Owner? /C1is ,tea
Yea 13No NEW RESIDENTIAL MECH.—SQ.Ff. (// -' `
I bane mad the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 undo round dam
if the building does eat cunenrly have a mnam,that it is my responsibility to notify the
awesome,of the requirements which must o met poor to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE