27580 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO H ,DING-ELECTMECH RL AL. PERMIT NO. O
APPLICATION/PERMIT PING PROJECT IDENTICAL
BUILDING DIVISION (WILDING PROJECT IDENTIFICATION
BUILDING wOYV]\,F$$: t� ` � SANITARY NO. APPLICATION SUBMDTAL DATE
1111LL / NITk I,OTN
O\WIRSNA IF� /J1 O 1 CONTR SN LIC NO:
I"• J•VVI, `%V1 / N/C COMROL#
ARCHITECP/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELT:CT PLUMB MEC11
PERMIT ISSUANCE ❑ ❑ -rl- ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL , „�'S/RyPI'ION
❑C'Z Ihereby affirmCENaEDCONTRA IOR'isDECL RATIO (commencing with .call/ /L�f✓\F/I
WOO Section 7000)of Division 34 the Business and Professions Codc,and my license is in PANELS
QuU tall force and effect.
nsc Class O 20) S
o<y DateContrvc]or 201 TIOW AMPS
ZQNZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLUOR AREA E/SQ.FT.
Oz-0 I understand on,plans shall be used as public records.
F W SIGNS ELECTRICAL
<,X$,"Ij [.iccused Professional
Y
W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOaF I hereby affirm(bat I um exempt from the Committees License Law for the
m40tn following reason.(Section 0031.5.Business and Ptofasinm Code:Any city or county TEMP.METER OR POLE INST.
F"—yam which requires harmine cunrvct
st .ahtt,impmvc,demolish.or¢pair any strvnum
}n prior to its issuance,also requims the applicant for such permitto file a signed statement POWER DEVICES
W C 0O that he is licensed personal to the provisions of the Contractor's License law(Chapter -
aXp�' 9(,ommcncing with Section 7")of Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
WMm of that he is exempt herefrom and the basis for alleged exemption.Any violation of OUTLF.'TS-SWITCHES-FIXTURES
F',Za Section 7031.5 by any applicant for ape.it subject,th/forsale(bcc.7
umm.civil InnallYn
nett re than five LunJreA dollars($SW).
SAG laxnwnerofthe t NEW RF;SIIIIiN'f1AL ELECTR —SQ.FT.
C� pmsidoll rm$500). yee,wilM1 wheirselecu sullen, STORIES TYPE CONS'IRUCfION
L'S22 JI o'he work.and the structure is not intindedorofkle(Sec.7 m,Business
and Professions Cede:The Contractors License Law apply r ofhi Iforthroughhisemployees,pmvidedthE]suchimpmvemen]sareno4 of( fmsale.ILhowever,the buildingor improvement is sold within onempl thcowner- TOTAL:
builder will have the burden ofproving that he did not bf Pu of❑ Lasowneroftheprolwrty.amexclusivel ironTY, PLUMBINGPERMIT FEE hTAOD'/,ONEyeo ed wn srsa APN
onslrum the project(Sec 71W4,Rosiness anJ .ao cit The Con s
License Lawdoes nm npplyman ownerof property ha bu Js mmpmvest ,and PERMIT ISSUANCE
whucontraces for.such projects with a con mr(s)li J ursuant m mm's ALTER
License law. DRAIN&VENT-WATER TTA) FEE SUMMARY
❑ I am exempt under Sec. B&r\ moor BACK PLOW PROTECT.DEVICE OUTSIDE FEES
no.,
YN
• (honer Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DIiCI. ON SCHOOLTAX YN_
❑ Ihereby affirm lbm lM1uveacenificate of amsenno self-insure,oracerificatanf FIXTURES-PER TRAP RECEIPT#
Wnrk.m'Compenxmimt lnsumnccnra CenlEedcopy thcreof(Sec.3800,Leb CJ which PARK FEE YN_
Is all employees ander this permit. GAS-Ii .SYSTEM-I INCA OUTLETS RECEIPT#
Policy R BUILDING DIVISION FEES
Company eeiGAS-EA.SYSTEM-OVER4 TA)
❑ CCertfied copy is hereby fumisM1ed. PIANCHECK PEE
❑ Certified copy is flet with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
("is sreinstated nm beeompletedifthe permit is[atone hundred dollars($100) SEWER-SANITARY-STORM EA.20I)EF. ENERGY FEE
u h,".)
I certify that in the perlumance ofthe work for which this permit is issued,I shall WATE TF.R WNENVELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
,Z C..Iwacalion lawsof Califomia. Date WATER AR SYS* ,TREATING Appllam Date Rmeiptp
Z NOTICE APPLICANT:If.at.,makingthis Cenificate of Exemption.yon should NEW RESIDEIMAL PLMB, SQ.EL TOTAL.
r_ V) becomesub*l to the Workerre
s Compensation previsions of the Labor Code,you must
� , fon o,III comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm lost them is a construction lending agency for the performance of
V O the work for which]his .it is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lenders Name
U.V Isnder's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE L
W 1 certify that 1 have real this ePlIicsfm.and state tat But above information is
F6. six.a.lagrm 1.simply with dl city and county ordinanees and star,laws reletingm PERMIT ISSUANCE MECHANICALFEE
_ (n building construction.and hereby authonze representatives ofidus city to enter upon the
U Z above-mentioned pmpeny for inspection purposes. ALTF,RORADDTOMECH. CONSTRUCf10NTAX
IWO agree In xave,indemnify and keep harmless rhe City of Cupertino against
llubihlics,judgments,costs Emit expenses which may in any way acerve against said City AIR HANDLING UNIT(TO 10,(X#]CFM)
invn'ynvare of tb Ening ufl ' pemti].
// AIR HANDLING UNIT(OVER IB.000 CFM)
Sigmamrco ppocanUComractor 7 Or. EXHAUST HOED(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO I00,000 BTU) Dam Rmeipt#
Will the applicant or forum building de.Chant nom or handle hazardous mammal
ars defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100,000 BTU) TOTAL:
CnJq Smti )?
11 Yet,
11 Yet, 11 No VENTILATION PAN(SINGLE RESW) �
Will the applicantorfnture building by the tune equipment ordeviceswhichemit q
BOILER-COMP CHP OR 100,000 BTU) ISSUANCE DATE
Disminus air contaminant,as defined by the Buy Arta Air Quality Managerncm BOILER-COMP(OVER IO ILM BTU) T A
UisWct?
❑Yes ❑No NEW RESIDENTIALMECH. SQ.FT.
1 have read the monstrous materials rtquirenten]s under Chapter 6.95 of the DEC 2 7 ��
California Health&Safety Cade,Sections 25505,25533 and 25534. I understand that
if he building does not ca"ally have a tenant,that it is my responsibility I()notify the occupant /s O—s�of the requirements which must be mel prim to issuance of a Cenifleute of Cf
Occupancy. UrV✓ -(/
Owner or auNonzcd agent Date TOTAL:
ISSUED BY:
OFFICE