27282 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI LDING-ELECTRICAL, PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING,PROJKC'F IDEN'I'IF'ICA'I'ION 27282
BUILDING ADDRESS SANITARY NO. APPLIC'nONSUBMIITT'ALr D'AIE
;?-,, d Ov DAG/A/Z.0 UNIT# LOTH 3
� If
WNERSNAMI9 �I PHONE: CONTRACT'OR'S NAME: LIC NO: -`-
� .L &'37 /"A"'# lax P1,06 e-62 C6.� / —3 TS-911Z N/C CONTROL#
�sC111"FEC 7ENGiNECR: LIC NO: ADORES& El
CONTACT: PHONE: G BUILDING PERMIT INFO
jg2� ScY�//fiO fs 4g�4/y(•�� QI Y. ELECTRIC PERMIT FEE
PL�B MECH
� PERMIT ISSUANCE Fl.l:�l'sL�lll
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
❑etz thereby oflin"don l am limmedundcr prnvisionmf CTepter 9 bommencing with
p00 Section 70001 of Division 3 of the Business and Rofeasionx Cade.and my license is in PANELS
full yUF :-icca rteUP T02W AMPS
and effect. �-f� �
F Z,� LiccnIs Clue hi<.N Sr
n6y Dam Contra (' 201-IOW AMPS
"Z. ARCHI'117 DECLARATIt N SQ.Ff,FLOOR AREA S/SQ.Iq'.
z r?� lundcrnund mY plans sM1all seJupublic record,
OVER lots)AMPS y p�
nf-ul SIGNS ELECTRICAL
Licensed Professional
Yom¢ IL
NER"BUDER DECLARAT IN SPECIAL CIRCUIT/MISC.
0 a F 1 hereby off mm;'I am exempt,burn the Conor, tar's License haw for the
3�m fnllowingreuv .(Scetion903L.S.Business and Protbenint'Cade:Any city or county TEMP.MEI ER OR POLE INS'1'. -yn2s p '9
which ca a permit to construct,alter,improve.dem ish,or repair any moisture
yYF per aces issuance,also requires the applicant for such Per in to file a signed statement POWER DEVICES
Y C,Oz the he is licensed pursuant to the provisions of the Contra or's License law(Chapter SWIMMING IDOL ELECTRIC
a LL 9(enumerating with Section 70(10)of Division 3 ofthe Bu. n sand PmfessionsCWe) VALUATION
0
-Zy Se tmheisea hy;toyrefmmmfi then iafonhc nllcged aemption.Anyvi0rallyof OUTLETS-SWITCH17S-171XI ORES �� —`
_E� Se mmll LShynondoodcant for pe cls Irplicanunaclvllpenahyof
i Z n ore Dan Ove hundreJ dollar i e
amt: m Lasownernfthepr y. yeeawithwag mthclrsolecarnpensuion. NEW RISIDENTIALELECIR SQ.FT. STORIES TTPF CONSTAUCI'ION
y3e-° w IJO Ne wn ,snit them fir'em/o
oralfcrt0 vle(Sec.]fIM,Businev
or I Pmfc"i C nwctoda Lirense d s not apply to an owner of
It
tied who proven thcreo end Jtrs such orkhimselfnr throughhis OCC.GROUP RES.UNITS
vidW that such mm� mentormm�ot imcndW nroffued for sale.IL
I rw eethehu di gorimprmiac x.ldwohio Oneycornfenmpinion,tM1cosear,
wilder will has t •burden - vingsthat he did not build or improve for purpose of
le,f
❑ Lasownero epro,mmy,am atcludvdy contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONC APN
mnrvct the next(Set.701E Business and Professions Code:)The Cmicatemrs
tDues not apply loan nnerofproperty who mildsorimpves tlmrcon,and PERMIT'ISSUANCE
It wrontmetm ler much injects with It conmaetons)Keenan!pursuant to ons Commeor'm
Lteenx Law. ALTEiR-DRAIN&VENT WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sm. ,B R P C for this moon BACK ROW PROTECT. CF. OUTSIDE FEES
SANITARY Y N
•hvmr
Date RHCFIPT#
DRAINS-FLOOR.ROOF,A ' OND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
\IhciebyallirmthntllmvcaccrtifnttcofconecnllosdLinsure.oracerti Cmumol FlXTUR1: PER TRAP RECEIPT#
tsBkeri Compcnanion lnsumnceoracenifiedcopythcreof(Sec,3gW,l.ab C.)which PARK FEE Y N
vcrssllemployKs d GAS-FA.SYSTEM-INCAOULCTS RECEIPI'at
Policy imb000 Su-9L
BUILDING DdIflSION FINS
Campion, 45- . 7b GAS-FA.SYSTEM-OVER 4 HEO PLANCHECK Fr l
❑ Certified copy is hereby furnished.
-9 Conified copy is filed with the city inspee inn division. GREASEONDIJSTRLWASTI?INTERCFET R GRADING IEE s"ammi
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS rE
COMPENSATION INSURANCE
(ThlssamilonneadnmbecamPlaW ifthcpermitia farenchuedraddoBas(SIW) SEWER-SANITARY-STORM EA.200 ENERGY
or less.)
I sonify that in the puforranccnfthe work for which,hic permit la is...d,l shall WATER HEATER WNFNT/ELECTR
noI employ any person in any n as ,,become subject In,the Workers' PAID
z Compensation Lwsrf Califomia. spate so WATIiR SYSTF,M?BEATING Date R cipitN
Applicant
) � NOTICE TO APPLICANT:If,after making this CeniGcac of Exemption.you should NEW RESIDENTIAL PLMB. SQ,FT.
V] become subject to the Worker's Compensation provisions of the labor Cade,you must
; ; Gmhwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE _#
? Q CONSTRUCTION LENDING AGENCY SEISMIC FEE e2A _
Z I hereby affirm that them is a construction lending agency for Ne performance of ELECTRIC FEF.
O the work for which this peradt is issued(Sat.3097,Cis.C)
Lenders Name
h lander's Add r..s QTY. MECHANICAL PERMIT FEE PLUMBING FEF, \
y (LI 1 certify that 1 have read this application trod male that the aMwn minm oma Is MECHANICAL FEE
correct, T agree m comply withall city unit county ordinances and state laws relating to PERMI I'ISSUANCE
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
'Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify and keep hasmlev the City of Cupertino agaim,
liabilities.juJgmcnb.costs and eapcnses which may in any way acermagairmt acid City AIR I IANDLING UNIT(TO 10,00(0)CFM)
in consequence of the grind tfm snot,
AIR HANDLING UNH'(OVER I0,000 CPM)
/.�- I/-I �
Signamrt of App�eaMContracwr pas EXHAUST HOOD(WpIUCD
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I0D.O(10 BTU) Dam Receipt#
Will the applicant or future building mcupam store or handle bavardoos material HEATING UNIT(OVER IINI INNI BTU) _
Is delincJ by the Copenino Municipal Calc,Chapter 9.12,and the Ilcalm and Safety
Cede Section
Yes No 255326a0?
❑ VENTILATION FAN(SINGLE RESID)
Q \
`• BOILER-COMP(3HP OR I WAW BTU) ISSUANCE DATE
Will lair"r venmrfumm building by the
Area Aim Quality
r Nq
t, "Ict) air comuminama as defined by the Buy Area Air QutJity Management BOILER 10(I,Of1O BTU) r'tr
Uiarlet, set 5
11 Yes N,g No NEW RESIDENTIAL MECH. SQ.Ff. �A
I have read the lost, has materials requirements under Chapter 6,95 of the k�
Califomia Health R Safety Cede,Sections 25505,25533 and 25534.1 understand that !I
if the building dors not currently have a tenant,that it is my responsibility to notify that �ry Gh LUri
ose,c,ono�f ins rt�quirtm,e,n�ts 'hien mom bemm odor m iasoance o!a Ceniewm of 4iN0
Own ,randodmd agent Date \ ISSUED BY:
OFFICE