27078 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUII.IJINr—hJACTRICAI. PERMII'NO, n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O 17
H
BUILDING PROJECT WENT IFIfXfJON 2
BUILDING ADDRESS: ,I TT'��//�� SANITARY NO. APPLICATION SUBMITTAL DATE
217''3 Mr CL.E .LLA&M FZ1D UNIT# LOT#
OWNERS NAME,: 1 i Q 1, CONTR R'S LIC NO:
TL!N'� -LI NJ 1 amcy NN CONTR L#
MIIIIIIIIIIIII,RCHITECT,TINGINEER: NO: ADDR IS ❑
Clpy(pR < 213T(o
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERM IT PEC
PIiRMD'ISSUANCE
M-08)"1'1C_3(S` BLDG ELEc PLUM MFCy
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GC> I hereby affirm that am 9
licensed underprovisions mChapter (commencingwith JOB DESCRIPTION
11100 Section'/OOOIof Ulvision 3of the Bminessund Profession,Code, nd my license iala PANELS
Iy�W l�-.. full lore and effect.
<FLW License Class Lic.# UP T02W AMPS �1
m<e- Date Canine 201-1000 AMPS Y
1-ss„Z ARCHITECTS DECLARATrds. S5 &AREA SJSQ.fT.
ZOm— OVER IOW AMPS /1{T1y11JI1
O Z—❑ I undemm�d my plans shall be used m public records.
ADA
P m b-W SIGNS ELECTRICAL t
<x�,....Il Licensed Professional
C
CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a OyCJ 1 hereby uffinn that 1 or exempt from the Com«cmr's License Lew for IM1c
'W 3 LL ot following anon.(Section 7031.5,Business and Professions Code:Any city ar county TEMP.MGIHft OR TOLE]NST.
0 which mluias a permit to conxwn,ober,improve,Demolish,or«pair any strucmm
nepoorto its issuance,also requires the applicant for such permit to file a signed statement
aPOWER DEVICES
W K< thin he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
ao 9(contmencing with Section 3oflhe Business and Professions Code) SWIMMING POOL ELECTRIC ^ VALUATIONor that
Way Sectiohei31.5 by nyap therefromandfor a permit
subjects no,
exemption.Any violation of 1 tg q11
_hZa vection PALS by hundred
dollBnupennit subjects the npplicum mecivil pcnahy of 11T1.ETS-SWITCIIliS-1'I%TURES l�`(TJ 1..(l L"
Pic than five hundreJ dollars(ESfg).
f�❑ NEW RI5IDENTIAI.ELIiCUt —SQ.FT. S'IURIIS TYPE CON59RUCTION
z e I,mawner ofthepstract.urm of intayedorofwa!for ldc(Sole Business 6'3= will ions CiAcandtlac Com oto isL is a se Law
and apply t 1Jan owner of
and Professions GWe:The Co roves cherco s License Law such
not apply if an owner or
)wnpim,penYwyol„pdsarimphal,uchcr,pro,c w,', aessucicndc himfff,,dbrough his
cmpinyces,pnwideJ tharsuch improvements are oat inlenAcd oroffercJ fnrsule.IL OCC.GROUP RES.UNI IS
h wcveo the baddingnr improvement it sold within one year of completion,the owner- JJTV
builder will have the burden of proving that he did not build or improve for purpose of ��
si1c.). PERMIT FEE QT PLUMBING
❑ I,mowner of the pmpeny,rem excluxivelY<ontracting with licensed contractorsw FLOOD LONE APN
ennswn the paject(Sm.7044,Business and Prefectures Calc. TM1 1 .
L.iceme Lawdoexnotapplytoh es
wuwnerafproperrywmmprovtterm ,and PERMIT ISSUA E
who conaaasforsuchprojectswithuttmtracmr( enxdpunuanuothe Conumbar's ALTER-DRAIN& eN'1'-WATER BEA) FEE SUMMARY
Cucmc Law.
❑ 1 am exempt under Sec. .B&P C for this reason BACK]LOW PROTE .DEVICE OUTSIUI:PI:1;
SANITARY V N
Owner Dae DRAINS-FLOOR,R .AREA,COAD. RECEIVI'p
WORKMANCOMPEN, TIONDECLARATION SCHOOLTAX YN
❑ Iherehyaffirmthmlhaveacerifica of Conant to self-imure,maaniticate of FIXTURES-PER TRAP RECEIPTp
Workers'Compensation Insurance or a Cott tied copy thermf 55,3800,Lab C.) hicM1 PARK FEE Y N
rsall employee's under this permit. GAS-IiA. YSTF-M-I IN 4OUTLETS
RF:CIiI 'p
PalicyN BUILDING DTVI. NFEES
CompanyYSTEM-OVER (EA) PLANCHECK FEE 6
❑ Ceaifiedcopyishereby fu mi shed. g
in, 4i
❑ Cenifiedcopyis filed with the city ins tion division. S D ASTEINTERCEPfOR GRADING FEE 1
CERTIFLCATEOFEXEMPIO FROMWOR 1 STRAP SOILS FEE _a
COMPENSATION IN RANCE
or less)w,v,nx nccdnntbecmnplvox,fthepc 1111sfur Uneh eddollaa(S SEWER-SANITARY-STORM EA.201 ENERGY FEE 1
I ecoifylhut in the perfo..mosoflhessorkfor hichthis pc stomed,l shall WATER HEATER W/VF.NTp?LECTR
of employ any person in any manner so as to oma Jce. m Be Workers' PAID
Comxacationlswsof CAifomia. Dae WATER SYSTEMTRFATING NA Receipt#
ZZ ApplicantVQn
0 NOTICE TO A PPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. 'TOTAL:
,Py become subject to the Worker s Compensation provisions of the Labor Code,you must
fa
� > nhwitM1 comply with such prwi,am,mmo,permit doll be deemed revoked. BUILDIbIO11W, 4 051
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby affirm that Dam is a construction lending agency for the performance of
U 5 the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC ME�� Lender,Name
Lenaera nanre,.a QTY MECHANICAL PERMIT FEE PLUMBING FEE
F
U 1 cam],Lha 1 have read This application end state that the above ioformaion is MECHANICAL ITE
LQ Curren. Iagree to comply with all city and county milinancesund am¢laws nelidart,aPERMITISSUANCE
I” N buildingrommuction.and herby authorize representatives ofthis city toemerupm the CONSTRUCTION TAX I
V Z above-mentioned property for inspection purposes. 02 1 ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap handers the City of Cupsmarm against
liabilities,judgments.costs and expenses which may in any way accrue against said City AIR I]ANGLING UNIT(TO 10.1103 CFM)
in a quence of the,parain,oftpe
his rmit.
ase
'7 AIR HANDLING UNIT(OVER 10,000 CPM)
e
Da
Sign are ill, a 1'of Appl Conpacmr Dae EXHAUST HOOD(WNUC17 PAID
lee�HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO I0p.000 BTU) Use Racil M
Will the applicant or future building occupant store or handle haysrdous material IIRATING UNIT(OVER 100,000 BTU) T
a,defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety
Cade,Seainn 25532(n? VENTILATION PAN(SINGLE RES]D)
❑Yes ❑No ISSUANCE DATE
the epplicantnr futurebuildingoccupanmxcyuipmemordeviceswhich emit BOILER-COMP(3HP OR 100,"BTU)
Will
�necessitates air contaminants as definW by the Bay Area Air Quality Management ' r
BOILER-COMP(OVER I 00.00)BTU)
Jita ict? p
❑Ye, ❑No NEW RESIDENTIAL MECH.—SQ.FT. L
SEP 8
1 have«ad the haaadous mmeda0 fequiremems under Chapter 6.95 of the .T
California l lealm A,Surety Cede,Sections 25505,25533 eant and 25534.I understand that / A
ifthe building does not currently have a nthat it is my maparnibility to notify the 84
�l�) vP
Cupar. � remmu
of the ruienu which ss be met prior to issusnce of a Cenificae of
Occupancy. ����,//r)Y( m
Owner or nuthno,ed agent Date T ISSUEDB1
OFFICE