27780 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II1I II.B NG.ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL _ 7 7 O O
I4UIhDING DIVISION BUILDING PROJF,C'T IDENTIFICATION 1 / v
BUILDING ADDRESS:� L ati / �D SANITARY NO, APPLICA'DON SUBMITTAL DATE/ 6 UNIT# LOl'4
OWNH&&, PHONE: CONTRALTOWS 1 LIC NO:
2 6 N/C CONT'ROLp
ARCIIITECf/ENGINEER: AC LIC NO: ADDRESS: ❑ ,
✓ CON'I'ACY PHONE: QTY, ELECTRIC PERMIT ITE BUILDING PERMIT INFO
_ RLDO ELECT PLUM MECH
PERMIT ISSUANCE I'[, F-1El .0
fI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENAL 1-•�
I hereby ffrm ihni l um licensed under (Cha Rr9 ommencin JOB DESCRIPTION
GCZ Yu provisio=n p n eis ih
PCC Seaiore(KKgof Division3 of the Business and Rofessions Code,end my license is in PANELS
,z full nSeC laJ,ffect. rte.
4Z, License Class Lic.p UPT02W AMPS
y Q y Ilam Comment 201-1000 AMPS
ZOy^ ARCHITECTS DECLARATION OVER IWO AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
C Z—O I understand my plans shall be used as public raords.
P:E~
QQ W SIGNS RLECOUCAL
C
Licensed Profeminnnl
0�Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISE.
CafU— 1 hereby aft ioexempt that I.m exempt from rhe Caserta'License Ism for the
uI�+P-vl which re tams a permit
to consumer,
r,sines and Professions Code:Any city Stcounty TEMP.METER OR POLE INST.
Jwhich requires a permit m conswcr,agog improve,demolish,or repair any rwaam
'n 2 micsissuance,al sore .ire,fta lien fo...ch Go file.ai ed statement POWER DEVICES
��ll prior y pp game gra
B)K A that he is licensed pursuant w the provisions of the Contrncmrs License Law(Chapter
aq�(o 9(oonnnenuing with Section 7000)of DiSiSi.U3 of the 9mme,sand Profeasinm Code) SWIMMING POOL ELECTRIC VALUATION
Hot, or Nm he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLIiTS-SWITCIlIiS-PIX'I'URFS
�G�
Section 7031.5 by any applicant for aperuit subjects the applicant.a civil penalty of
tax more than five hundred dollar(8500).
t� NEWRE.SIDCNTIALL'LECTR .F1'.
`—o ❑ otss owner anddpmperty.ormynnpluyed orofwedforshei(See.Tom,Businean,ss STORIES TYPIiCONSTRUCfION
n,3= will dmhework,
nsCdtheswmu=isnot is License Law dim
70,14,Business ,
and Professions Code:'I Coneacmra License Isw Jas nm apply to an owner of
properly who builds of improves cherton,and who arcs such work himself onhrough his
wnempiny,es,pmvidcJ that auchimpmvementa um not intendedoreffercdferwle.If. OCC GROUP RFS.UNITS
however,the building orimprovement is sold within oneyear efcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
s l,).
❑ 1,asownernflhepmpeny,amexclmivelyconaactingwiNlicensedcom=tomo QTY. PLUMBIN ERMIT FEE F1Q0 ZONE APN
constrict the project(See.7094,Business and Professions Code)The Conbacmrs
License Law does not apply to an ownerofpropeny who builds orimprwea therm..end PERMI'1'ISSUANC
IV
who contracts for such projects with a com=emgs)licensed pursuant to the Coulraevsrs
License Law. ALTER:DR ffiVFNI'-WATF.R(FA) ITF,SUMMARY
1 am exam er Sec. ,B&P C for this reason BAC OW PROTECT.DEVICE SA ARY Y Di_N
er Dme RECEIPTM
WORKMAN COMPENSATION DECLARATIO RAINS-Ff.00R,ROOF,AREA, 5 OOLTAX YN
. ❑ 1liemhy:dfrn that l have a certifcateofconsennnsel6insure.m iteenifctteof RECEIPT#
Wofken'Com FIXTURES-PER TRAP
pens=ion lnsurvrce or thcrcoffga.]eW,Leb CJ which 11ARK FEE, YN
rs all employees under this permit. S-HA.SYSTEM-1 INC.4 '1. S
RECEIPT N
Policy p BUILDING DIVISION FEES
C❑ Codified
GAS .SYSTEM 8\ 'A) PLANCHECK FEF.
fied copy is hereby fornishW.
❑ Certified copy is filed with the city inspection division, GRHAS DUSTRL .TNTERCEMR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE M\P SOILS FEE
COMPENSATION INSURANCE.
(This Section rad not be completed ifthe permit is fora.,hundred do)[.FS IW) SEWER-SANT RY-STORM .200FT. ENERGY FEE
orle".)
I certify that in the perfewance ofihe work for which this permit is issued,l shall WATER HEATER EM/ELEC`E
not employ any penton in any munne,so as t. herniae,Subject mo the Workers' PAID
Z Compensation Lewaof California. Date WATER SYSTEM/-REA NG Date Receipt#
Applicant
FC NOTICE TO APPLICANT:IL after makogthis Cenifrcate of Exemption,y..,doeld NEW RESIDENTIAL PLM9. S .I7. TOTAL:
V) became subject m oho Worker's Compensation Provisions of the Lahr Cale,you must
a. 1 forthwith comply with such provisions or this Permit shell be damcd revoked. BUILDING FEE �.
W m~z CONSTRUCTION LENDING AGENCY SEISM IC FEE
^� I hereby affirm that there is a cons metien lending agency for the peribmance of
U O the work for which this permil is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
D. Lender's Name s PLUMBING FEL'
Lenders Address QTY. MECHANICAL PERMIT FEE
V I certify that 1 have read this application and sonic that the above information is
correct.l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MECIIANICALFEE
�^ y building cmmstrucrion,and hereby aurhonce repms,naoives either city to enter upon the ,
CONSTRUCTION TAX
U 7 above-mentioned progeny for inspection purposes. AL'I'ERORADDTOMECI I.
G (We)agree to save,indemnify and kap hmmless the City of Cupertino against
Iiahilities,judgmetns,conIssendexile which may a any way accrue agaimist said City AIR HANDLING UNIT(TO 10.000CFM)
incense .•.^r•yCgr.ntin of a nnit.
/`/ AIR HANDLING UNIT(OVER 10,0(10 CFM)
9meture of Applicant/Consenter ate EiXHAUSTHOOD(W/DUCU
PAID
HAZARDOUS MAI URIAIS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material
US derided by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety I IBATINC UNIT(OVER I WSW BTU) TOA
Code,genion 25532(87
❑Yes ❑No VEM'ILATION PAN(SINGLE REBID)
Will tair co ica.licals s defined
by thenmSe Area Air Quality Management
BOILER-COMP(311P OR 1 00,000 PTU) ISSUANCE DATE
hevmrdous air conmminents as def red by the Bay Arca Air Quality Mnnagemeno BOILER-COMP(OVER 1110,000 BTU)
DisulctP �pk
❑Yes El NO NEW RESIDENTIAL MECII. SQ.IrPp
. F O D
I have rend me havddous materials requirements under Chapter 6.95 of the IIA
Caffnmi.Ben0h&Safety Code,Sections 25505,25533 and 25534. 1 undersand that R 7 1995
if the huilding does not cummly have a tenant,that it is my responsibility to ramify the N1A
cecupant of the me iremrnts which must he at prim m issuance of o Cerificaoe of
OcC°'em' CIIY UI-
Owner or uwhnrizeJ agent pate TOTAL: ISSUED BY:
OFFICE _