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27232 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO unintl.LNG-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUM ROJECTFIDENTIFIC 27232 7 2 3 2 BUILDING PROJECT IDENTIFICATION L BUILDING Z' 1C ©A S If f77NITis LOTH SANITARY NO. APPLICATION SUBMITTAL DATE OWjif�S -- �V_,^� PHONE: J`J / UCOpITRACTOR' A a �Q LIC NOQ O /W' VA 5f C' NIC CONTROL# RCHI'IECf/ENGINEER: LIC NO: ADDR,SS: ,' arr- � s. - 95�a $ CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ' PERMIT ISSUANCE ❑ ❑ El LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION p.Z I hereby affirm that l am licensed under pmvisionsof Chapter9(commencingwith 00 Section 7")of Division 3 of the Business and Professions Code,and my license is in PpNF,Ls yy��U full force and¢flet',? nor 1 UP T0200 AMPS FZy, License Class Lit..# 15�a,J`oO V,<c. Data Convector 201-1000 AMPS S FT.FLOOR AREA $/SQ.FT. zOv^ ARCHITECTS DECLARATION OVER IOW AMPS Q O Z'-'a I understand my plans shall Im used as public records. N W I SIGNS ELECTRICAL E Licensed Professional �E C'w< OWNER-BUILDERDECLARATIONthe CoATION SPECIAL CIRCUIT/MISC. OyU I hereby affirm that I run exempt from the Contractors License Lew for the , W r C)ti following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. LS ON; which requires a permit to construct,alter,improve,demolish,or repdr any structure N}� #dorm issuance, its alsorequires the applicant for suchpermit to file a signed statement POWER DEVICES Gp that he is licensed pumuam to the provisions of the Contractors License Law(Chapter 4ie 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTURES QSection 7031.5 IF vny applicant for a permit subjects Meapplicant ma civil penalty of 0 morethanfiofthepodrty.ormyem). NEW RESIDENTIALELECfR _SQ.". STORIES TYPE CONSTRUCT ION Qn n❑ Las wok and or ofwagsasafei(sole compensation, a3— wnlemthe wm(k,dna me amacmreianmrntenaedmrmrmreefor ade(sea.7o44,east and Professions Code:The ConOecmrs License Law dos not apply 0 an ownerlk property whobuilds or improves thereogand whodoes such workhimselforthrou is own employees,provided that such improvements manotintendedmOffered So le.If, DEC.GROUP EIIN�::NITSpletieowner- TOTAL:builderwillhavetheburdenofprovingthatheaidnotbuildorimpr for purpose ofI,as ovacrofthe property,amexclusivelycon with licensed counumfore to QT' PLUMBING PERMIT FEE FLOOD ZONE construct he project(Sec.0044,Imorm Professions Code:)The Commences pER IT ISSUANCE00 License Lawdoesnotapply to an ownerdfproperty who builds or improves thereon,and whocionects for suds projects with commands)licensed pursuant to the Commences License Law. AL -DRAIN&VENT-WATER(W FEE SUMMARY ❑ I am exempt and Sec. B&P C for this reason BAC FLOW PROTECT.DEVICE IITSIDB FEES SANITARY Y N Owner Data DRAT S-FLOOR,ROOF,AREA,COND. RECEIPTq WORKMANCOM :NSATION DECLARATION SCHOOLTAX Y N Cl Iherebyaffi(mthatlhaveacerti'cam ofcomenuoself-insure,orn certificate of FIXTURES-PER TRAP RECEIPT# Workere'Compensationlnsumaceore ttified copy thereof(Sa.3800,Lab C.)which PARK FEE Y N covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT# Popuyyp BUILDING DIVISION FEES Company .SYSTEM-OVER4(PA) 'r PLANCHECK FEE' [ICadified copy is hereby fumished. ❑ Certified copy is filed the ti rvision. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFI E '0' FR E GREASETRAP SOILS FEE COM SA ON.1 SNkCE (This section need not be c late ifthepemi1 is onehundutldollars ) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or less.) T I certify that in the perfornanceof a work for which this Permit is cd,Ishall WATER HEATER W/VENOELECTR nut employ any person in any mann as to become subject t he Workers PAID Compensation Lawsof California. Dat se WATER SYSTEM/TR1ITING Date Receipt# 0z Applicant z C) NOTICE TO APPLICANT:If,after in ing.fln, rtificat Exemption.you should NEW RESIDENTIAL PCMB. SQ.Pp. TOTAL: lA become subject m the Worker's Camps etlon pmv o of the Labor Code,you must forthwith comply with such provisions this p r stshall be deemed revoked. BUILDING FEE �W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is i sued(S .3 lending agency for the performance of p .U0 U z TOTAL: ' 36.�. ELECTRIC FEE O the work for which this permit is issued(Sec.3099,Civ.CJ Lenders Name u" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE is LUTII certify that I have read this application and state that the above information is MECHANICAL FEE a correct.Iagree in comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE Cn building construction,and hereby authorize represents es of this city to enter upon the above-mentioned r CONSTRUCTION TAX U popery for inspection putpoue. ALTER OR ADD TO METH. gree to save,indemnify coify antl p harm) the City Cupertino against liabilitiee,jo ment,wsts wde w ch may' any way accrue against said C'y AIR HANDLING UNIT(TO 10,000 CFM) in consequen a of the grentin f it. ✓ .O AIR HANDLING UNIT(OVER 10,000 CFM) _ e ! S,gp.tdV.f Applica Comracmr Da EXHAUST tI000(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT(TO 100,000 BTU) J Doc Receipt# Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,(100 BTU) / T L as refined by the Cupertino Municipal Cale,Chapter 9.12,end the Health and Safety Cwk 3eui❑Yes s32(s)'! ❑No VENTILATION PAN(SINGLE RESID) r'^ I DA E Will theapplicantmrfuturebuildingoccupent uuequipmentordsvicas whichemit BOILER-COMP(3HP OR 100,000 BTU) azardous air cotnaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) TSI f�� ®}� ,x-,a - 'sm 1 l�'(�9 28 'WVaW4 ❑Yea ❑No NEW RESIDENTIAL MECH.'� SQ.PT. ' 1 have read the hazardous materials requirements under Chapter 6.95 of the all, UI' J'U I IN California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that ' if the building dues not currently have a tenant,that it is my responsibility to notify the acumen of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner in amhorized agent - Dmf TOTAL: ISSUED BY: OFFICE __