27773 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPURTINO PBUILDING-LUMBING-MECHANICALEPERMIT NO.
BUIsnwG DIVISION APPLICATION/PERMIT27773
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:yy�I � -y�/!' SANITARY NO. APPI.111 TIONSUBMITTALDA'IE
Irl .� 11(IfaO IAT IF S
0 E SNAME: I PHONE: COS NAME: IC NO:
N 'Ile VD�� NC CONTROL#
ARCHITI:C/EN INEER: IC NO: ADDpEfS;�r CCC--JJ ❑
67"1
CONTACT: PHONE:
QTY. ELECTRIC RMIT FEC BUILDING PERMIT INFO
BLDG ELECT FLAME MUCH
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I JOB D RIPfION
mwz Iherebyaffrrm that l am licensed underpmvisionsofChapter9(commencing wird &
WOWO Section7000)°(Division Sof Ne Business and Prefessimu Code.and my liana u in PANELS
'k!❑J full force Weffat.
FzzmLicense Clan Lica UP TO 200 AMPS
m 6gX
Vr Date Contractor 201-1000 AMPS
ZOyF4ARCHITECTS DECLARATION OVER I"AMPS SQ.PI'.Il RARG $/SQ.FT.
OZ-0 I underworld my'lens shall be used as public records.
F y t SIGNS ELECTRICAL
Q Y j Licensed Professional
�yK6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ippi55,,O y tVc-.. 1 hereby from that 1 oro exempt from the Commerce$Liceme Law for the
m'3 ma following resector.(Section 703 1.5.Business and Professions Code:Any ill.,county TEMP.METER OR POLE INST.
which rcquircs a pomtit m colonel,shes,improve,demolish,or repair any stnnurc
>-� prior to in issuance.also requires the applicant for such permit to file a signeduatemenr POWER DEVICES
O that he is licensed puruanno the provisional of the ConaactMs License Law(Chapter
n K 9(commencin with Seetion 7005 ftivision J ofthe Business arW Professions Code SWIMMING POOL ELECTRIC
oy, ars'' )° ) VALUATION
order he is exempt hercfrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
QSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollen($500).
0 ❑ I,nowncro❑heprapmy,ormyemployeuwiN wagsntheirwlecompenation, NEWR651DIPTIALELECR _SQ.PP. STORIES TYPE CONSTRUCTION
63Lo will do the work,and the structure is not intended or offered for aide(Sm.7044.Business
and Professions Code:The Continuous License Lew door not apply to an owner of
propenywhobuildsorimpmvesthemon,and whodoes such work hlmselfortluoughlom
dedthatsuchim OCC.GROUP RES.UNI'T'S
however,me cs,provi provld within
forme.".
however,Ne building m improvement is sold within ane year of completion,the builder have the burden of proving that he did not build or improve for purpose of
s1eJ
❑ I,ns ownerofrhepmpmy,smemlusivdycontnding with licrnudcontrctonm QTYPLUMBING PERMIT FEE FLOOD-LONE APN
construct the Project(Sec.7814,Business and Professions Cade;)The Common's PERMIT ISSUANCE
License Luw docs not apply m an nwne r of pmpcny who bui ld r ar i mpmrvu thereon,end
whocomranx for such projects with amntioctor(s)licensed pursuantlothe Comracmr'a ALTER (PA)
License Law. EEE SUMMARY
e;zP underSe, ,B&P C fm Nis reason BACK FLOW PROTECT.DEVICE ID
SANITARY Y N
DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTa
WOR MAN COMPENSATION DECLARATIO SCHOOL TAX YN
❑ IhereM1y uffinnt mlhuvencenificaners"msem m sof-Ensu eceniEcete of pTXTUNES-PER TRAPr"i RECEIPTa
Workers Cnmpensnrion Insurance oracenified copy thcrmf(Se.I ,Lab C)which PARK FEE Y N_
covers all employees under this permit. GAS-EA.SYSTRM-I INCA ETS OUTLRECpl"N
Policy p BUILDING DIVISION ffgk
Company OAS-EA.SYSTEM OVER 4(EA) PLANCHECK FF.E
C1Cenifiedcrlynherchybeanhed.
❑ Cenilied copy is filed with the city inspection division. GREASWINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE.Op EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This—line need not be mmpleted ifthe Permit is fmonehundreddollan($IN) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER GRATER W/VENTIF.LECTR
not employ any perme in any mmner w as rn become subject to the Worker' PAID
Comsomanionlawsof California. Date WATER SYSTEMIMPATING Z Applicant Data ReceiplN
z� 0 NOTICETO APPLICANT".If.after making this Cornfields of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L-: ► become suhject to the Workers Compensation provision of the labor Cade,you must
lei forthwith comply with such Provisions or this permit shell be decreed rovoked. BUILDING FEE 'a
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 z
I hereby afbrm tbm there is a construction lending agency for the perf.ci of ELECTRIC FEE
V 0 the work for which this permit is issued(Sm.3097,Civ.C.)
D. 2 Lender's Name
0 Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 coni ley that I have reed this application and ante[het dee above intonation is
G{ mrrnd.Ie tee mcom th ell cit erW coum rdinances end note laws reletin m MECHANICAL FEE
B hereby
e PERMIT ISSUANCE
building aonmrec6an,and herebyauNoriurtpssea. vu o(rhie city memtt upon the
L) z above-mentioned progeny for inify and keepwn. ALTER OR ADO TO M[C CONSTRUCTION TAX
(We) dgagree nt save,indemnify and kap hummy in
the City cr Cupertino id City
liebilitie,judgments,cosh and expenses which may in any way accrueegeinmsaid City AIR HANDLING (TO 10,000 CFM)
in consequence of the granting of this permit.
AIR IIA INO UNIT(OVER In,WO CA theP
Siroof en atm D7XIIAUSTHOOD(W/DU(
PAID
RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100pWBTU Duk Receipt#
Will the applicant or future building occupant store or handle hazardous national
as defined by the Curtino Municipal Code,Chapter 9.12,and the Health and Safety INTEND UNIT(O I(A' ) TO
Caption
Code,Section 25532(a)7 V gT1ON F RESIDJ
❑Yea ❑No
Will the upplicantorfumrebuildingoecupant macquipmentordevices whichmn, BOILER- MP(JIIPORI TU) S A�.'CaFLDATE
h andous air contaminants as defined by the Ray Area Air Quality Management BOILER-CO (OVfeR 100,000 •„1 3 p�Jf
iso cfl RAR p
❑Yes ❑No NEW RESIDENT L MECH. SQ.ff.
/57�IS
1 have read the hazardous materials requirements under Chapter 6.95 of the C/ry UF,C, vOO
Califumia Health&Safety Code,Sections 25505,25533 and 25514. 1 undersand tom
if the building does not currently have o tenant.that it is my responsibility to notify the
occupant of the requirement,which most be met prior to issuance of a Cor ificnrc of
Occupancy.
Owner or authodmd agent Dare TA L: ISSUED BY:
OFFICE
I
RLL STRELYHRLI wo, 2-
114-7 walb
CONSULTINO
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