27677 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLumemc-mKcxnrvlCAi.RICAL PERMIT No.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 21677
BUILDING ADDRESS: I (I SANITARY NO. AP�PLICA/TI.ONSUBMITTALDATE
1O-7s f� 1 C0. S UNIT LOT /
O NER3 NAM PHONE: CONTRACTOR'S NAME: LIC NO: 2-4
1. \_
NIC CONTROL N
L4 '29-7RCHITF.CT/ENGIN ER: LIC NO:� ADDRESS: �• -� ❑
'ONTACT: PHONE:
`ad�. QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
tS 8 _ BLDG ELECT PLUMB 'MECH
PE-C7,701 1RMIT ISSUANCE IQl E
LICENSED ONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL W pg asccrnn•.
PooMetz I hereby affirmthat l amllrensed underprovisionsof Chapter9(commencingwith �1►v/_+(rys�,
Section]OW)of Divisio-3 of the Business and Professions Code,and my license is in ppNELS
full force and effect,
QV Licim CIbra _ Lic.N D-1UP TO 200 AMPS
v1,6'y
Date
Craft or Gol.f� 201-IOW AMPS
APS
ARCHITECT'S DECLARATIO OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z'-'❑ I understand my plans shall be used as public moorth,
p..rn fz"q SIGNS ELECTRICAL
sQ M Licensed Professional
K-Iu - OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC,
0, I hereby affirm that 1 am exempt from the Commences License Law for the
3 m m following reason,(Section 7031.5,Business and Professions Code:Any city m county TEMP.METER OR POLE INST.
pJ which requires a permit to construct,alter,improve,demolish,or repair any structure
gin prior wits issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
<0 that he is licensed pursuant to the provisions of the Convenor's License Lew(Chapter
40.p�- 9(rnmmencing with Sedion]0007 of Division3o(the Business end ns Code) SWIMMING POOL ELECTRIC VALUATIOy4a
iW--„� orthat he is "a
therefrom end the basis fonhe alleged exam n.Any via ' not CJT�^
1-.Za Section]031.5 by any applicanr forapermit subjects thea cant toe civil pen o of OUTLETS-SWTTCHPS-FIXTURES �� 2O OOj1 �.
url
�R 0 morethan five fthepmddmllnmye 0). NEWRESIDENTIALELECB _SQ.FT. STORIES V TYPECONSTRUCTION
n❑ I,asowneroftheproperry,mmyemploycesw' ages astheirsolecompensetion,
y willdo the work,andtheswnureis not intended offeredfmsale(See.]04q Busimess
and Professions Code:The Convectors Li se Law does not apply m an owner of
property whmbuildamrimpmoes thereon who does such can,
his
employees,providedmatsoch' mems me not imendedmoffered beside.If, OCC.GROUPL RES.UNITS
however,the building crimp ent s sold within one yearofcompletion,theowner- '
builder will have the bard ofpmving that he did not build or improve for purpose of
Ie.).
❑ I,as owneraft p.o .y,amexclusivelycomvectiagwithlicensedco torxm QTY. LUMBING PERMIT FEE FLOOD ZONE APN
crhsrun tha Pmie (sec 7044,Business arta Professions Codep Tna con ors '
Licensclawdmes mtapplytounmwnermfprowaywhnbuild orimprov err .end PE IT ISSUA E
whocnmructs fora hprojecte withaconvacmr(s)licensed comm of C toll TE GRAIN& NT-WATER(EA) FEE SUMMARY
Liwnse Lew.
❑ 1 am exempt un r Sec. ar thie reason OUTSIDE FEES
BA7K7FLOW PROM DEVICE _ SANITARY Y N
Owner DRAINS-FLOOR,ROOF, REA,COND, RECEIPT R
WORKM COMP SATI DE AU0N SCHOOLTAX Y N
❑ Thereby affmm thatl he acertif of int se1Gi are,ore car aloof
RECEIPI'N
Workers'CnmPena on lneuran orece a thereof( ec. W1196CJ ich FIXTURE TRAP PARK FEE Y - N
e, overs all employee's under this it. - RECEIPT p
PalicyN GAS- A.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FEES
ComPanY AS-EA.SYSTEM-OVER 4(EA) PLANCHECK FRE
❑ Ceadied copy is hereby furnished.
❑ Certified copy is filed with gravity in tiondivision. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXIMPTIO OM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSU CE
(ThissctionneWnot ee mpletedifNepermitis fo ehendradd ($IW) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I certify that in Ne performance ofthe work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
act employ any person in any manner Vas m become b' t to the Workers' PAID
Compensation Laws of tCalifomia. Date /� WATER SYSTEWIREATING Date Rise k
O z. Applicant JL of
NOTICE TO APPLICANT:If.after making fill Certificate of Exemption,you should NEW RESIDENTIAL PLACE. SQ.FT. TOTAL:
p] become subject to Ne Worker's Compensation Provisions of the Labor Code,you must -
�i ; forthwith comply with such provisions or this permit shell be deemed invoked BUILDING FEA \ / /A
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE �.
Vz I herebyaffare that there iss construction lendiagagerey fee me p oformanceof ELE 1 r
O the work far which this permit is issued(Sec.301 Civ.C.)
Lender's Name
C) U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBIN E
W 1 realty Net I have reed this application and state that the above information is MECHANICAL FEE
comet./agree to comply with ell city mW county ordinances and state laws relating to PERMIT ISSUANCE
h7 4 building construction,and hereby autboriae representatives oftbiscity to enter upon the CONSTRUCTION TA
U above-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabllities,judganatD,costs and expenses ich may marry way accrue agaimstsmid City AIR HANDLING UNIT(TO 10,000 CFM)
he gen'in
I th
guis ens ^^ AIR HANDLING UNIT(OVER 10,0010 CFM)
Si reof pplicanUm
Corado Dem EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSUREHEATING UNIT(TO 100,0010 BTU) Date Receipt
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TO L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)4
❑Yes No
VENTILATION PAN(SING LE RESID)
�
ISSUANCE DATE
Will theapplicantorfuturebuildingoccupanl meu,nipment ordevices which emit BOILER-COMP(3HP OR IW,OW BTU)
mandate air contaminants us defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disvictlo p
❑Yes NEW RESIDENTIAL MECH. SQ.FT. /�� "1 /®
I have read the hazndous materials requirements under Chapter 6.95 of the ^ /�
California Health&Safety Code,Sections 25505,25533 and 25534,1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the - v
occupant of the requirements which must he met prior to issuance of a Certificate of F L.
Occupancy.
Owner ar awhmiaed agent Date TOTAL: ISSUED BY:
OFFICE