27042 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-El,F. ,RI A PERMITNO. 27042
1 �O/s�1 T Z
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'IFICAI']Ory L
WILIJI//NG ADDRoISS: /■I // SANITARY NO. APPLICATION SUBMITTAL DATE
I �0 UNITM A LOT# [OL lAstassar
OWNER NAM + PI NF.: �� CO A A E'
•/ N/C CONTROL If
BCHIIECf/UN N_ER: LIC NO: AM5K�M4~13,lf ❑
7�0
PPHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT'INFO
-�) BLDG ELECT PLUMBPERMIT ISSUANCE ❑ ElLI SED CONTRACTORS DECLARATION APPLIANCES-RHSIDENI'IAI. JOB❑FSCRIPTION
Iherebyalfi h IamlicemedundcrpmvisionsofaVter9(eommencingwiNtcllo m andt,fDi ' nn sfthe Businessen nfessions ClMe, nJ my licem,is in pANF:IS
W llforeandeffecUPTOSW AMPS
Zicense Cbtssfff---rrr------Lic.#
yo6Z Date J�i.�.il! /I�. Contractor ILII-IOIXIAMI'S
ZOOV'Z 1� 1 a ARCHITECPS DE OVER IWAMPS SQ.ET.Di00R AREA E/SQ.FT,
OZ-0 I mode ntand my,runs shall he used as pt hlo records.
Ftn(=o� SIGNS ELECTRICAL
gild Licensed Pmfexsioaal
W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ca�SO o,F 1 hereby affirm that 1 am exempt from the Contractors License law for the
nl�O vs fol lowing musmv(Section 7031.5,Business and Professions Codc:Any city m cmmq TEMP.METER OR POLE INST.
y which requires a Permit to construct,alter,improve,demolish,or repmr any structure
` >-1 Erma.its issuance,ulaorequires theapplicam Boston pemdU.fileasignmm<m ed amPOWER DEVICES
<p that he is l wensed pursuant to the provisions of the Contractor's License Law(Chapter M
p•o•0 9(commencing with Section]000)o(Divisinn 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the bods for do Wlegod exemption.Any violation of OUTLETS-SWITCHES-FIJ(TURP.S
�QSerino 7031.5 by any applicant for.pcsmit subject.the applicant m a civil penalty of
A not more than five hundred dollars($500). NEW RESNFNTIALHLECfR _SQ.FT.
W m ❑ I,asowneroftheproprty,ormyemploymswithwagesotheirsolecompe..tion, STORIES TYPE CONSTRUCTION
L will do the work,and uhesoursure is not intended proffered notion,(See.7044,Business
and Profession.Code:The Contractors License law does not Hmly to an owner of
property who builds or improves thereon,and who does such work himmlf or through his
ownemployem,providWN.tsuchimprovemenismenotinlendedoro(femd(nrs.le.If, OCG GROUP - RES.UNI IT
howev,n the building or improvement is sold wiNin one year of compinion,the owner-
oulderwillnavethehurdenof that he did not build or for u f TOTAL:
proving p purpose
ale.).
❑ I,00wnemOhc prnpeny,amexclnively conuractingwith li«.Wconunnorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cn.tmcl the project(Sec.7044.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Lawd«snot apply town owncrof properly who huddsmrimprovexthereon,and
who counsels forsuch projects with a contractions)licensed pursuant othe Contractor's
License Law. PETER-DRAIN&VEN ATIiR EA) FEE SUMMARY
❑ 1 am exempt under Sec ,B&P C for this ma on IIT, D FL
BACK FLOW 1'ROITiCT.UEVI
SANITARY Y_N
Owner DateRECEIPT#
DRAINS-FLOOR RHA,C
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm thmlhaveticenifeme of consenuo self-insure,oro cenifmme ofRECEIPT#
Fl%TUR ER TRAP
Worken'Compcnsatiun r�sYYrm a yal :of(S..3g00,lab C.)which PARK IEE Y N
covers ell employee t Ib t GA A.$Y$TIiM-1 INCA UTLFTS RECEIPT,
Policy# BUILDING DIVISION FEES
Comp. GAS-EA.SYSTEM 1 FL.ANCHECK FEE
❑ mlfietl copy is ombyfomished.
14 Certifiedatpy is filed within,city inspection division. GR SHA T . ASTE IN R GRADING FEE
xCERTIFICATE OF EXF? PTION FROM WORKERS' GW401 W-07—
SOILS PEE
COMPENSATION INSURANCE
This section need not be completed ifthe permit is hunts hundreddol (5100) SHWE - N .7060 EA.200FT. ENERGY FEE
o.IcoJ
I certify that in the performance of the work for which this permit is i Iananl WATER RATE ENT/ELECIR
not employ any person in any manner so as to become subjects to the W.L 11. PAID
z Compeasetico Lmsof Califomia. Date WATER SYSTEM(ITEV1'[NO Data R.ipt#
Applicata
0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ TOTAL:
LI) hecnme subject come Workda Compensation provisions of the Labor Coda you must
Forthwith comply wild such Provisions or this permit shall be domed revoked. BUILDING FEE
a [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) z Ihereby affirm that there is a construction lending agency for the performance of
C) O the work for which dima)rmit is isstmd(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
C) U Lenders Address QTY. NUCHA AL PERMIT FEE PLUMBING FEE
CLI I certify that I have mad this application and suite that the above innnmwuion is MECHANICAL FEE
Q-. correct.l agree to comply with all city and county ordinance and sate lewsreladng to PERMIT IS ANCE
building construction,and hereby authorize representativesohhis city tnemer upon the
C) above-mentApmnyersionpuALTI?RORADDTOMF,CII. CONSTRUCTION TAX
(We) "nod k p harmless the City of Cupertino againstIiubilitins,jmewIchmymanywayaccr vagal stsaid City AIR HANDLING UNIT(TO 10,00(1 CFM)
conseqehis I AIRHANDLING UNIT(OVER 10,010CF1,)
SigrodumodApplicluBl4contronor m EXHAUST HOLD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0IX)BTU) Dam Receipt#
Will the applicant or future building«cupant store or handle he tandous material IIHATING UNIT(OVER 100,000 B"1'U) TOTAL:
as deEncd by toe Cupertino Municipal Cole,Chapter 9.12,and the Health tied Safety
Cale,Section 25532(a)?
El Yes ll No VENTILATION PAN(SINGLE RESIO)
Will thea applicant buildin «cu BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
PP or future 8 panwseequipmentnrdevica whichemit
haamn.,uiz entnamin..is as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Oindcd 12
Dyes ❑No NEW RESIDENTIAL MGCfi. SQ.FT. tri
I have read thW,ly
, oux materials requircmemx under Chapter 6.95 of the ®�/� a 19
CWifpmia llrahh& SI•ty adsSectio.25505.25513 sud25534.1 undersuanddot
if t he building datentinh that it is If,responsibility to notify thethent he met prior m issuance o(.Certificate of ?'Vf U
occupancy. (J
Ownerorhori R Date TOTAL: ISSUE
aulD BY:�
OFFICE