27879 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .Bar PEHMIfNO.
APPLICATION/PERMIT PLUM ROJECTECHN I HFIC
BUILDING DIVISION IIf111.DING PROJECI'IDEN'1'IM'ICA'1'[ON 27879
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMIITTTAALDATIi
1 ! 1 _ /1 UNIT# LOT#
OWNE 5NAME: fn PHONE: Cj TRACTORS E: x LIC NO: J
_ I 1 fLll NIU CONTROLp
RtHrrOcyliESGINEER: LIC NO: R 956q
❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El e2i� ❑
LICatl=lmnCONTRACT
rMvi DECLARATION APPLIANCES-RESIDENTIAL JOB DESCR
Oe'Z Ii meby7") ff l 3 ofhe sedinss and ieionsio Cheplee,and mmencise wish �/. \�..A - 'l11\V{�•
�DOO Semion]OPU)of Division3of the Business and Professions Code,and my license is in PANELS
ne'1F-.. 1'a 11 force and cff
FzW License C1. 'Z L. UP T0200 AMPS
may Dale Contnnor L 201-111110 AMPS
F
'Vi
RCI I ITECTS DECLARATIONSQ.FT.FLOOR AREA S/SQ.ET.
z0S,— l understand my plana shall be usedus public records. OVER IIHIp AMPS
oNF W SIGNS ELECTRICAL
Licensed prafeasimnal
4'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC.
XOyO I hereby affirm that I van exempt from the Conneanr's License Law for the
In 3 a y¢ following mason.(Section 7031.5,Busineo and Professions Cade:Any chy m«umy TEMP.METER OR POLE INST.
F u'O J which requires a permit to construct,alter,improve,demolish,or repair any structure
Sd aE prior to its issuance,also requires the applicnntfor such permit to fife a Sign ed atatemem POWER DEVICES
that he is licensed pursuant tat the provisions of the Contractor's License Law(Chapter VALUATION
daoK 9(commencing with Section]Ilgl)of Division 30f dte Businessend Profession Cade) SWIMMING POOL ELECTRIC
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
�7Q Section 0(131.5 by any applicant for a permit subjects the applicant to a civil Penalty of
f2<a nm morethan five hundred dollars(550(p). NEWRESIDFIPIIALELECIt _SQ.FT. STORIES TYPECONSTRUCTION
S'Fp ❑do
work,
anhepropcny,ormyempinded wilhwegoned ole(Se.c0hL Business
Lia- will do the wons and e:The Contture ractot is License
intended does not apply
to car owner
and Professions Code:The Contractor License Law does not apply w an owner of
property whobuildsor imptovestherson,and whodoessuchwork hindielfor Wough his
employees,providedthat such improvememsitoom imendedoroffered forsaie.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofcompletion,themmer- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I.aanwnerofthepmpeny,umenclusivciycomractingwithlicensedconvucwnto
construct the project(Sec.]IK4,Business and professions Code:)The Contractor's
Licenselawdoesnot apply wan ownerofpropeny who builds m impmvesthmean.and PERMIT ISSUANCE
whommacufnrsuchpmjmtswithacomractorts)licenscdpumuutwt Cmn toes
License Law. ALTER-DRAIN&VENT-WATER(G7 FEE SUMMARY
C]nl am exempt under Sec. .13&P C for this reason BACK FLOW PROTECT.DI3VICE OUTSIDEFEES
SANITARY Y N
Owner 1 Dale DRAINS-FLOOR,ROOF,AREA,COND. RBCEIPI'p
WORKMAN CO i A ]ON DECLARATION- SCHOOL TAX Y N
❑Workers
Co uponthatInsurance
nshave acmlfcelaofconsemwalf(Sesure,or Lm C.)ate ofwhich
FIXTURES-PER TRAP RI?CF.IPTN
km,eirs 11 emplyee,code,11ancanraoenifedcopy @ere0f(S«.3800,Lab C.)whicM1 PARK FEF; Y N
covers all cmployds order this permit. GAS-EA.SYSTEM4 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTHM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumisM1M.
-;i9. Cenifed copy is fled with the city inspection division. GREASEDNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('1'his action residual he completed ifthe permit is Came hundred dollan(EI00) SEWER-S NITARY-STORM EA.2(gFT. ENERGY FEE
1S
I certify that inthe performanceinyMa of the work for which this bject to theWIshail HEATER W/VENT/CLECTR
not employ any person in say manner so abject to the Woken.' PAID
O Z Compensmio�bL s California.' Datum hc-kb .t « WATER BYSTEM/IREATING Date Receiptp
Applicant
Z 0 NOTICE TO APP CANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' cl) become subject to the Workera Compensation provisions of the labor Code,you must
foMwilh comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
Gj Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thatthem is a construction lending agency for the performance of
U O TOTAL: ELECTRIC FEE
the work for which this pemtil is issued(S«.309].Civ.CJ
Lender's Name PLUMBING FEE
u' F Lendersndereaa QTY. MECHANICAL PERMIT FEE
U 1 certify that I have read this application and slate that the above inf arram m is MECHANICAL FEE
>" W cmrrect.lagr«mcnmply wilM1 all city end county ordinances and slate laws relating to PERMIT ISSUANCE
F-' buildingeonuuction,and hereby authorirc representatives ofthis city tenter upon the CONSTRUCTION TAX
Umisswocntioned ptorny for inspection purposes. ALTERORADDTOMECH.
(We)agree to.save,indemnify and keep harmless the City of Cupertino against
Iiabilitius,judgments.costsand expo ses whichmay inany way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in conn arae f the nu f Ni permit.
0 AIR HANDLING UNIT(OVER IO.flgl CFM)
61 Signatumof Applicant/Comm,tor . �Iqc I EXHAUST HOOD(W/DUCT) PAID -
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0)0 BTU)
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW.000 BTU) n'-� TOTAL
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health enyd Safety _
Cade.Section 25532(al? VENTILATION FAN(SINGLE RESIDE r V� t p 6
❑Yes '�(Nn ISSUANCE ATE
Will thea licmtorfummbuildin tune mntordeviceswhichemit BOILER-COMP(JHPOR I00.000BTU)
PP Bby the quip
hazwdnux air contaminants as defined by the Bay Arca Air Quality Management BOILRR-COMP(OVER 100,000BTU)
District? .W
❑Yes No NEW RESIDENTIAL MECH. SQ.FT. w � e
1 have read the hamnloua materials requirementS under Cholla fi 95 of the
if the uil Health s Safety currently
r Cody,Section 25505,.it is and 25534. I understand that IT
if the building does not m n is w have.tenant,tent itis my responsibility to notify the C�%Y
cupant of the requirements which must be met prior to issuance of a Certificate of C/p f
Occupancy. rr.
Owner or authorized a gent Dale TOTAL: ISSUED BY: C��