27155 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Ba¢DBrc-RcecTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBIN G-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIF'ICNHON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
wzLIc azo 6 z a
UNIT at LOT
OW ME: PHONE: CONTRACTOR'S NAM LIC NO'.
V N/C ONTROL
CHITECTRNGINEL'R: LICNO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG, ELECT PLUMB MECH
PERMIT ISSUANCE IIyT/�I� ❑ ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTIONm PCZ Ihereby affirm that l smliemaedunder provisionsofChapca9(commencingwiN
wooF Section]000)of Division 3 of'be Business asW Profusions Code,end my liaae is in PANELS
QUU full force and effete.
(_Zed License Class Lic.0 UP TO 2W AMPS
Dale Co..., 201-1000 AMPS
ZOonz, ARCHITECTS DECLARATION OVER 1000AMP5 SQ.Ff.FLUOR AREA $5Q.Ff.
OZ�G lundenand my planashdlbumadmpublicmcorts.
F.m m SIGNS ELECTRICAL
Q` d Licensed Professional
g9=U OWNER-BUILDER DECLARATION SPECIAL CIRCUUMISC.
Axx'OyI hereby affirm Nan 1 but,exempt from IM Conuncnora License law for the
W 3 vFai following season.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
I'r%..1 which require.a permit to concoct,alter,improve,demolish,or repair any swaure
Y� prior to its issuance,daarequbes Ne applicant for such Permit to file asipial turnaround POWER DEVICES
04!R G p [but he is licensed Formal to the provisions of the Contractors License Law(Chapter LL0X 9(commencing with Section]000)of Division 3 ofthe Business and Profeesions Code) SWIMMING POOL ELECTRIC VALUATION
p},�y orthat he is exempt therefrom and the basis for the alleged exemption.My violation of
F� Y� Session]031.5 by any applicant fore pnmei[subjautehe applicant noecivil penury of
r
deOUTLETS-SWITCHES.FIXTURES
not mthan Five dreddoller ). S
❑ 1,..wne, fthepmprty,ormycmPloyaswithwgasasshiolec . NEWREIDPNTIALELEC1t SQ.PG
m , STORIES TYPC
ONSTRUCTION
a w[lldo Be work,and the smactute lsnollntnded moffrW Parricide(Sm.7M
Business
and Professions Code:The Contractor's License Law does not apply to an owner of
prope ry who bui Ids or i mprov es thereon,and who does such work himself or through his
employins,provided than suchimprovememsere notimerMedmoRered faaale.If. OCC.GROUP RES.UNITS
however,the bui I d ing or improvement is sold within one year of completion,the owner-
builderwillhavetheburdenof poising that he did not build or int TOTAL'
pr g prove fm purpose of
ale.).
❑ Lasownerofsheproperty,amexdusivelyconwcting wishlicenuJ conuasmnm QTY. PLU NG PERMIT FEE FLOOD ZONE pPN
construct the pr.jcc,(Sec.4044,Business and Pro&anions Code:)This Oonnacmr'e
License L.wdoa nolapply in an ownerafmaperry who builcis air improves themon,and PE IT ISSUANCE
wmecamsets formch projects wish.ommumr(s)Reausedpnsuat to the Contractors MR PEE SUMMARY
Licaso Law. MJO
❑ I am exempt under Sec. ,B&P C far this reason pCK FLOW PROTECT,DEVICE SANITARY TY N
Owner Dam DRAWS-FLOOR,BOOP.AREA,COND. RECEIPI'w
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
I herebyafion that l have.Certificate ofc.t In self-insure,or a ccrtificaa of FIXTURCS PER TRAP RECEIPTx
orkeri Compensation laimmerm,ceNBedenpy thereof(Sec.3800,Lab CJwhich PARK FEE Y_N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'x
Policy x BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 EA) PIANCHECK FEE
❑ Cenifedcnpyisherebyfumished.
❑ Certified copy is filth with Ne city impact.division. GREASFJINDUSTRL WARE IWrNtHFJrOR ADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This secrionmadnathe completed Hum permit isfor one hundcandelollue(SIM) SEWER ANI R ORM EA.200 ENERGY FEE
of less.)
I certify that in she performance of the work for which this permit is issued,)shut WA WIVENTIELCTR�
not employ any pmom in any meaner u as to became subjal m 0m Workers' PAID
z Compensation Laws of Celifomie. Data WATER SY E VDD Data Receipt as
Applicant
O NOTICE TO APPLICANT:If.atter nuking this Certificates of Exemption,you should kNEW RESIDENTIAL PLMl3. SQ.FT. TOTAL:
(q become subject o the Workers Compenation provision of the labor Code.you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
V
Z I hereby affimirm that them is a concoction lending agency for the perfortnena of
O the work for which this pert is issued(Sec. FE
3197,Civ.C.) ELECTRIC E
G. Leaders Name
Lender's Address QTY, MECHANICALP ITTOT FEE PLUMBING FEE
0 V I certify that I have read this application and nam that Ne above Information is
concert.I nex,tu comply with of city anal county ordinances ane swe laws reladngmPERMIT ISSUANCE MECHANICAL FEE
�' pn building construction,and hereby outhoriu represenu[ives ofthiscity lumberman the CONSIRUCfION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify aM kap huMesa the City of Captious,against
liabilities' enu,msts and expares which may in any way aarue against said City AIR HANDLING UNIT(TO 10.000 CFM)
e of[he gra[i pe it.
AIR HANDLING UNIT(OVER 10,000 CPM)
Sigmome pplicinUCamntnr One EXHAUSTHOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Raceip
Will use applicant or future building occupant stare or handle hazardous mmerid
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Heal,and Safely HEATING UNIT(OVER 100,IX3 BTU) L:
t still
Code,Section 25532(e)7
0Yes 11 No VENTILATION FAN(SING LH EESID)
WillUheapplwintarfnurebg pantuxe9uipmemordevicawhich ami[uildin cmu BOILER-COMP(3HP OR I0LM0 BTID ISS NCE DATE
'ndims air communes[.as defined by she Bay Area Air Qudity Management BOILER-COMP(OVER 100,000 BTU)
w
J ❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.PI'.
1 have read the hazudous materials requirements under Chapter 6.95 of the (Cr
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undersand that
if the building does not currently have a Leant,Nor in is my responsibility to notify the
mcupann of the requirements which must be met prior to issuance of a Certificate of (Jr
Occupancy. Lurk,
f
Owner or umhoriaed agent Dam TOTAL: ISSUED BY
OFFICE