27300 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOH.DI h 1x1 AL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
ULINGIIIROJEIF)PN'IIFIl AAIJON ::n'^-;7-;y�s'"'
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PERMITNO.
O O O
J
UILD11N'GAADDRESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
MITA LOT#
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❑
CONTROLp
ARCHITECT7UNGWEEW LICNO:
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ADDMS:V,\ �^Cr
CONTACT: PHONE:
-
QTY. ELECPRIC PERMIT - FEE
BUILDING PERMIT INFO
BLDG EL�gC/� PLUMB ME
❑ IJl F ,
Ex
s
_
/ PERMIT ISSUANCE •OO
I hereby WthatIaDCONTRACTORS DECLARATION
n with
des sedBu rofess my
pppLIANCES- RESIDENTIAL
//'��Y
ppryBLg
70[gh m0rmthaG 3 of ss and
Section 7000) ifDivision3of the Business and Professions Code. and mylicenu is in
i ions Code. and lice,.
full force and if
Go—{_f�`]+(V[)_ L//F7Q'YK-f+Y+4.
t
Lice, Ins Lin,#
UP TO 200 AMPS
Unto Contrecam
ARCHITECTS DECLARAT
I understand my plans shall be used as public records.
201 - I" AMPS
OVER 1000 AMPS
SQ. PT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC..W
I hereby vffrm that 1 nm exempt from the Contractor's License Law for the
,
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit m concoct, alto, improve, demolish, or repair any eweurz
priorto its issuance, also requirtsthe applicant for such pemdt rofle asigr.dsutemenr
POWER DEVICES
that he is licensed pursuum to the provisions of the Commerce. License Isco (Cbapnr,
9(commencing with Section 7000) of Division 3 of the Business and professions Cade)
SWIMMING POOL ELECTRIC
VALUATION
or tam he is esempa therefrommtd the basis forrheulleged exemption. Anyviolmiooaf
Section 7031.5 by any applicant for a Permit subjects the applicant too civil penalty of
OUTLETS - SWITCHES -FIXTURES
t more than five hundred dollars ($500).
❑ compensiness
NEW RESIDENTIAL. ELECIR _SQ. FT.
STORIES
TYPECONSTRUCTION
othewnemfNepstrutuormyemplay«swithwagesatheirwle
will do Codthe mmeu.ianar's ml 7D44,Business
^
�esions Licensormiand e
and Profession Cade: The Contractor's Lew does
La does apply lf an owner of
apply
red who
proown ertywbees, proorimFlravesth improundwhn mdoes mctandedimselredforugahis
or
n employeex,providedthm not lmendcdoroction,
int
OCG GROUP
RES. NITS
TOTAL: .
ver is mid witsiin ocowneL
Che ossa ofr.
however, the have the b r improvement is and he duln one yur at improve
builder will have the burden reforming that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ I, as ownerofthepropeny, am exclusively convecting with licensed rommcronu
FLOODLONE
APN
rostrum dx, projee (Sec. 7044, Business and Professions Code:) The Commean's
License Law doesnot apply to an owner of property who builds or improves the.an, and
PERMIT ISSUANCE
who contracts forsuch projects with acontrvemr(s) licensed pursuam to the Convectors
License law.
ALTER ES
A( 1Oka
FEE SUMMARY
❑ Tun exempt Come Sec. ,B&P C for Nix.awn,
BACK PLOW PROTECISUEVICE s,
.-
SANITARY Y N
REClill'l'#
Owner Deter
WORKMAN COMPENSATION DECLARATION
❑ Ihereby affms that l hove a certificate ofconsenuo self -insure, or a«nificate of
Wmkerd C=Mutionlmurumeore«eiftedcopythereor(Sm.38M lab C.)vdrichr'
DRlJINS': FLOOR, ROOF. A F. ND.
SCHOOLTAX Y N
RECF.I"a
_ "FIXTURES -P%
s
'•q
PARK FEE Y N
coven all 1 'e' ( r.-
Policy Y.~
Gpg JB^1p�.S TEM -1 T
i+.- M..tT
RECEIPT#
BUILDING DIVISION FEES
Company TsiaQ, ,
❑ ertifed copy is hereby famished.
. SY'F
GAS -EAsM V
PhANCHECK FEE
GRW �DUS' W EPP R -�a'
GRADING FEE
Crmfiad copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKER 1
COMPENSATION INSURANCE 4
' CREASE ,r,•�'d'
1,a
SOILS FEC
,g -SANITARY -STORM CA.2001T.
ENERGY FEE
(This section need not M1e completed lithe permit is for one hundred dbllars($100)
or less.) '
WATER HEATER /VENT/ELECfR
,WA7`ER SYSTEMRREATING
Data Receipt
Icenify that in Che performance of the work for which thio Normal . sehard,Ia11a11
.at employ any person in any manner so as to become subject to th Warktss'PAID
Compemmion Lawsof Calimand. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you 06W'Y
become subject to the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FFR
1 hereby affirm that them is u construction lending agency for the performance of
(he work for which this permit is issued (Sec. 3097, Civ. CJ
Lenders Natne
TOTAL:
ELECTRIC FEB
Lender s Address
QTY. .MECHANICAL PERMIT FEE
PLUMBING FEB
1 «Wily that 1 have rtvd this application and xmm that the above information is
correct. T agree to comply with all city erM county ordinances and state laws relating.
PERMIT ISSUANCEMECIMNICALFF.0
- L
K
building construction, and hereby authoriurepresenatives of thiscity to emnupon the
above-men[iooel property for inspection purposes.
ALTER OR ADD TO MCCH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cuperino against
liabilities,judgments, costs and expenses which my in any way werue against said City
AIR HANDLING UNIT (TO 10,010 CFM)
into eofthegramingof is omit.
7
AIR HANDLING UNIT (OVER IU,gO CIM)
Si [u enf Applican4ContrC137
cmr GorEXHAUST
HOOD(W/DUCT)
PAID
HEATING UNIT (M 100,000 BTU)
HAZARDOUS MATERTAI DISCLOSURE
Date Receipt#
Will the applicant or four, building occupant store or handle hseadous material
a definW by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
BEATING UNIT (OVER 100," BTU)
TOT
Code, Sxtion 25532(a)T
1:1 Yes 13 No
VENTILATION FAN (SINGLE RESID)
W illthevpplicanaor(uurz M1uildingwcupumtae equipmemnrdeviceswhiehemit
BOILER- COME DUE OR 11100 BTU)
ISSUANCE DATE
BOILER- COMP (OVER 100,000 BTL)
eraodan air conuminanb as defined by the Bay Area AG Quality Management
iatri 1?
^
❑Yes El No
f"
P
NEW RESIDENTIAL MCCH. SQ. FT.
I have read the hamok us materials requirements under Chapter 6.95 of the
i
Cmifomiu fieahh & Safety Crede, Sections 25505.25533anand 25534. 1 unders mal that
ifthe building does not currently have a lament, then it is my responibility to notify the
n `
C// O
occupant of the requirements which most be met prior to issuance of a Centifrcale of
h \7al+yLLplr//gip
Occupancy.
L
ISSUED BY:
Owner r um mind agent Data
TOTAL:
OFFICE