27576 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY Of CUPER'PINO BUILDING-ELECTRICAL FERMI rNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, 27576�5��•
BUILDING DIVISION - BUILDINGPROJKC'1'IDENTIFICATION J V
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
V UNIT# LOTH 00'1 _"
OWNfkS A PHONF.1 CONT ACTOR'SNAMP: • LIC NO: `Y
OAT
LL 15do td D G NlC CONTROL#
ARCIII 'B '/I?NGINIIER: LIC NO: ADDRESS: �f O
CONTACf: _4A 126
PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El r$- ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFNTTAI.
Qeez Iherebyafftnmhat l an licensed underpmvisionsofCaapter9(comenencing with JOB DISCRTFT[ON
�00F Section 70001 of Division 3.fthe Business and Professions Code,and my license is in PANELS
place
pQ.,Zu: Limnse Class 4—Lia# �40yib `� UP TO 2000 AMPS
rn7 y Contractor 201-I(gq AMPS
2Oy^- A CIII'TEC`PS DECLARA'110N' OVER IOfI(IAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
O Z-0 l undersmnd my#luta 0mil be umd as public meads.
pc��W SIGNS ELECTRICAL
RY � Licensed Profeaio
smnl
,�,�,, OWNER-BUILOPR DECLARATION SPECIAL CIRCUIT/MISC.
�OyU I hemhy oflimt that 1.,in exempt farm the Conlractm,,License Law for the
W B W rFjr following reason.(Section 01131.5,Business and Professions Code:Anycity oraomny 'LIMP.METER OR POLE INET.
which m,mm,nPennin,cumwcl,ilter,improve,demolish,.,repair anystrucmrc
tY�Q� mitsissuance,alanrc resthen applicant forsuch tat filen, et,womment POWER DEVICES
prior qui pp panni get
W�SQO that he islicensedwith Smantmthe of Division
Contractor's License Law(Chapter
SWIMMING POOL ELECTRIC
4qo�' 9(unnmencing with Section]fgt0).f Division3nf the Business end Professions Code? IAA'IION�
XW, o, or that he is exempt herefrom and the basis for the alleged exemption.Any violation or OUI'1 LTfS-SWI'TCIIBS-EIX'NRFS
1=KQ Section 7031.5 by any aptlicant far u permit subjects the apifcntm aa civil penldry of
not marc than five hundred dnllms(S5f10)'
C�o ❑ I,asnwnernfthe progeny.ormyemployceswith wags nstheirsolecompcnsatinn, NEW RBSIDIiNTIAL ELLCfR _SQ.FT. S 1 .0 NSTRUCI'ION
or, willMnhe work,and theswctnm is not intended oroffered for sale(Sm.7044,Business
and Pmfesslons Cal[:The Contractor's License Law does not apply to an owner of
propenywhobuildsorimpmvest cn n,=dwhodaes such work lJmselfor Nrsughhis ROU wNJ RFS.UNITS
nemplayces,pmvided Nat such improvementsminte
anor nderim.fferrd forsalw If.
however,the building or improvement is sold within one yearof completion,theowna- TOTAL:
builder will have the burden of proving that he did not build or improve for Fryom of
le.).
❑ 1,ae ownentfrhepmpeny,emeaclusivelyc.ntmning withlicensed convactonto QTY. PLUMBING PERMIT FEE 11 ZONU APN
consumer the pmject(tics.7004,Business and Professions Cade:)The CmarxetorsI'GRMD'ISSUANCC
License Law does not apply to an ow ne r of pmpcny who builds or improves#aeon,and
whocantracts for such pmjects with acontmaorad licensed pursuant,the Conoan.rs ALTER License Law, WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason RACK FLOW PROTECT.DEVICE SANITARY Y-4 N
Owner Date RECEIPT'#
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N_
❑ eraC y affirm arcomimn Immoreacenifcamedcopy n to them.l(S..38M,acenifc te of
hick FIXTURES-PER TRAP RBCBIPf#
Workerx'Cmnpensutinn lnsuruncc oracenifeAcopy thereof(Sec.3g00,Lab C.)which PARK FEE Y_N
cnvmsall employee's undcmhis aconicGAS-EA.SYSTIiM-I INC.4OUTLETS - RECEIPI'll
Policy# BUILDING DIVISION FEES
Company GAS-IA.SYSTEM-OVER 0(EA) PLANCI IBCK FEE.
[I Certified copy is hereby furnished.
❑ Certified carry is fled with the cityinduction division. GRI?ASIVINDUSTRI.WASTE INTERCEPTOR GRADING FEE:
CERTIFICATE OF IIXEM17ION FROM WORKERS' GREASBTRAP SOILS FTSE
COMPHISSAI'ION INSURANCE
This Senion need not he completed ifthe permit is f.rmahvndred dollars Pdrd)) SEWER-SANITARY-STORM FA.20017. ENERGY FEE
.,less.)
I ernifythat in the pe,fmm:mermfthe work forwhreh#iisperand isissued,I shall WATER HEATER W/VFN'DELF.CIR
not employ any person in any manner so as to become subject to the Workers PAID
Z Compensation Lawsof Califomia. Date WATER SYSTHMTRIIATING Date ktt<iptN
Applicant
z2 NOTICETO APPLICAN'11.If,after nursing this Cenifcam.f Basal......Mould NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
f" V) become subject o the Workers Compensation provisions.fihe labor Code,you must
a. 7 forthwith comply with such pmvisionx.,,his permit shall be deemed revoked. BUILDING PEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
D z I hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
U) r, Lenders Name PLUMBING FEM.O U lenders Address QTY. MECI IANICAL PERMIT FEE
I minify that 1 have mad this application and state that the above information is
H0. cmrect. Iagrtemenmdly with all city wA mumy oNinances and scam laws relating to PERMITISSUANCE MECHANICAI.FEE
building construction,and hereby authorize representatives afthis city to enter upon the - CONSTRUCf10N TAX
V Z above-mentioned property for inspection partners. ALTER OR ADD TO MECI.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
IiaM1ilities.judgmems,embund eases which mayinany way accrue against sua City AIR HANDLING UNIT(TO IQ0g10CFM)
arecquence of the grna . t .
AIR HANDLING UNIT(OVER 10,000 CPM)
Sig est - mate nr F 12_ Dam EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITTO 100,0d0 BTU) Date Receipt#
Will the upplicurnnr future building occupant storeor handle hazardous material HEATING UNIT(OVBR I(q,fNIB BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section YSe532(a)1 ❑No VEbD LA1'ION PAN(SINGLE RISID)
Willtheu Iirean orfmmcluildin .ecu amuse BOILER-COME(311P OR IN).N10 BTU) ISSUA#N�,CE A'TE
pp g p AreaAen Quality
Management 40,q
District? sir c.ntwninants az defined by the Bay Area Air Qualify Manegemtnl BOILER-COMP(OVER 100,000 BTU) ry
District] ®� o
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.Fr. ^e
1 have mad the hazardous materials 5505,25533 under Chapter erste nd the "mss?
if
Imia Ilendh s Safety Cale.Sections 25505,25533 and,prowi 1 undo rmfif that
if the building does nm runts w have a rowel that it is my mspnce of
a notify the
.ecupsnt of the requirements which must be ten prior m issuance of a Centigrade of
aaapaney, by -
Owner or awhorized agent Date TOTAL: ISSUED BY:
OFFICE