27336 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO11 LDIN,-ELF IRCAI. PERMITNO.
APPLICATION/PERMIT YLUMBINI:-MECFNII ICAI.
BUILDING DIVISION BUILDING LI]N(:r luEn'"rIFIL'A']ON 27336 G7 3 36
V
BUILDING ADDRESS: AA SANITARY NO. APPLICATION SUBMITTAL DATE
3�� AccNf L/ le g�7
UNIT# I.OTp
OW ERS NAME: PlIONE: CO�NTIR OR'SNAME: _ LIC NO: NIC COMROLp
�N S-
• RCHITECI'/ GINEER: LIC NO: ADOR2!ii �� El
�N/TL DAXS OE' p WC
CONTACT: PHONE: BUILDING PERMIT'INFO
QTY. Iil,IiCTRIC PERMIT FEE
BLDG L'LECi' PLUMBMECfI
PERMIT ISSUANCE IGT
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RESIDENTIAL TIO ,
py,Z Iherch'Afirmthat L am licensed under provismrsof Chapter9(commencing with JOB DESCRIPTION
POU Section
e ltiorce�)of Division 3 ofthe Businessland Professions Code,and mylicenu isin PANELS
6j� I,iccnse Clusa tl.ic.ali�! ( �'S ee
UP TO 200 AMPS
r/~jQy Doe Contractor 201.1000 AMPS
F-yz ARCHITECTS DECLARATION SQ.FT.FLOOR AREA WSz C r�'
OundershootI undershoot my plans shall he used as public recoNs. GVHR 1000 AMPS
Fye W SIGNS ELECTRICAL
Licen.'d Prolessional
y�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°JOd V I hereby affirm that 1 am exempt from the Comme o's License Law for the
tai+ TEMP.METER OR POLE INST.
V c, milowing o mon(Secuan 7031.5, y city or county
Business and Proussio-Code:An t t
which rcyuircsapermiuoltheconstruct.alteramprovuch Per ish.mrcpairany swcmrc
�5. }E prionoiu issuance,also requires the appliamfor such Permit file asigstW smmmem POWER DEVICES
u1ap0 that he is license pursuant to the provisions of the Commmor's License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
g'gx'olas, H(eommeneing with Su'tmn t0f8B of Dlvision3of the Business and Professions Code)
W—h or thm he is exempt hcrcfmm and the basis for the alleged exemption.Any violation of
�7a Section 7031.5 by any applicant for a p mansubjeus the applicant to a civil penalty of OUTLETS-SWITCHES-FlXTUR[S
F.S
not more than five hundred dollars(55(10).❑ NEWRESIDENTIALELECIR SQ,PT. STORIES TYPE CONSTRUCTION
a3=° ❑ oche wrk,an thestructurerm of intndedorthwagesusale Pick compensation,
will dotheand s:11he mumiamoes License
Law doeial s of apply to4i.owner
of
ss
and Professions Codm'ITe Convector's L.icenu Lew Jura not apply to an owner of
pnrpcny who builds in improves theram,ned whodocssuch work himselfomhrough his
n employees,provided that such improvemenisamerm intended oroffcod hassle.If,
OCC GROUP RES.UNITS
however,the building in improvement is sold within one year ofanmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sola). PLUMBING PERMIT FEE Q'I'Y.
❑ I,asowner of the propeny,um exdusivdy contracting with license convucnmm PLWU"LONE AI'N
consvun the pmject(Sec.71104,Business and Professions Cad.:)The Contractors
License Law duration apply manownerofpmpenywhn Wildsorimprovss thereon.and PERMIT ISSUANCE
who mmrams forsuch projects with a contrackals)licensed punmm to the Contmemrs gC1ER-DRAIN&VEN'T-WATER(EA) FEE SUMMARY
Liana Low.
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE.
SANITARY Y N
Owner Date DRAINS-I'L(IOR,RWP.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ih...
byaffiren that l hive.sWificmeofconseat to self imme,mitexetificauofRECEIPT#
FlXIlIRFS-PIiR TRAP
Workers'Compensation lnsonme—cenified copy thercam(Sec.3800,Lab CJwhich PARK FEE Y N
cs.1le I RECEIPT#
GAS-FA.SYSTIiM-1 INC.4 OU'1'I.IiTS
�
Put icyp "� - ai3-95^Qoe� •z77 BUILDING DIVISION I�F.ES
Comp Y 'r��l'F' �e1W D GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
23 Bed copy is hereby famished.
Ccnilicd copy is filed with the city inspectiondivision. GRFASMNDUSTRL WASTE IM URCEPTOR GRADING FEE
CERTIFICATE OI'EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMP17NSATION INSURANCE
(JTisscctionnadnot the complete if the permit is future haodre d.11...(3100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
as less.)
Icertify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compemallnn Lawsot Califomia. Date WATER SYSTEMITREATING Date Receipt#
Zz APPlicam
� NOTICE TO APPLICANT:If.after making this Cenifeate of Exemption,you should NEW RES]DENTIAL PLMB. SQ.FT. TOTAL:
hecnme subject to the Workers Compensation Provisions of the Labor Code,you must
> forthwith comply with such provisions or this Permit shall la,deemed revoked. BUILDING FEE
LU [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) z Ihereby affirm that there is a construction lending agency for the performance of
U O the work for which this permTOTAL: ELECTRIC FFaiit is issued(Sec.3191.Civ.C.) G
Lueders Name PLUMBING FYI;
0 F Lenders Address QTY. MECHANICAL PERMIT FEE
U I eerily that 1 have rend this applir tion and state that the above information i. MECHANICAL FEE
>' I1-I conal. Ingre.lu comply with all city and county oNinarv,,mdsmmlwsrcl.fl.1lo PERMIT ISSUANCE
tbuilding concoction.and hereby authorize mpmunmtivesofthiscity to enter upon the CONSTRUCTION TAX
U z above-mentioned propcny forinspatioo puryoscs. ALTERORADDTOMECIL
c)agree to save,mdse��ntry and keep harmless the City of Cupertino against
iabili es.judgmenu, Is rocs bmay in any way nccrue ag'nst sold QQQry AIR HANDLING UNIT(TO IQIXX)CFM)
o uyucnm of the granyngpf this it /
✓�Z// AIR HANDLING UNIT(OVER 10,0110 CFM)
2
5 namrcnf Appa:aMCooraanr Dat. 13XHAUSI'II000(W/DUCT)
tj PAID
HAZARDOUS MATERIALS DISCLOSURE / HEATING UNIT(TO IW.000 BTU) 6/ W Date Receiptro
Will the applicant or future building occupant store or handle Nostril material HEATING UNIT(OVER 10LOW BTU)
TOTAL:
us defined by the Cupertino Municipal Cock,Chapter 9.12,and the Health and Safety
Code.Section 25532p)? VF,NTILATION FAN(SINGLE RESID)
ID Yea ❑No
ISSUANCE DATE
Will thea,,lican-fine rvbuildingoccupantuseeyuipmem ordevi«swhich emit BOILER-COMP(3HP OR 100,0011 BTU)
haeodom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00(1 BTU)
District? 7
❑Yes ❑No NEW RESIDIiM'IAI.MUCH.-SQ.FT.
I have read the haaniolm,maadaE"mrsencnts under Chapter 6.95 of the
Cnlifomia I lealth&Safay Code,Sections 25505,25533 end 25534. I undermmid than
if the building Jur,mo currently hove a must
hic,that it is my rcsprrs,of ty a notify toe
occupant of the uquimments which must M sen prior no issuance of a Certificate of
Occupancy.
Owner or amhori'ed agent Doe TOTAL: D ISSUED BY:
OFFICE