27193 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B711I:BtNG-ECHCTRICA. PERMITNO.
BUILDING DIVISION BUILDING PLUMBING-MECHANICAL. 1 n
BUILDING PROJECT'IDE:NFIFICA'1'ION 1 J
BUILDING ADDRESS: SANITARY NO. APPUCATIs•ONN�.SUBMITTA�/LDATH
I V 1 Q lk/ UNITM LOTH tris( y
O NF.RS AMI?: ,a.7J HO CONTRACTOR'S NAME: s. LICNO: \
U / �(�(✓h `1 [L � O YG L {• } u M a• • N/C CONTROL p
aHCi11'1'IiCI'/IiNGINMR: LIC NO: �^SS1
:��1 *e7 //
F 4W 'ONTALT: PHONE:
QTY. ELECTRIC PERM11 FEC HUILDING PP.I2MIT INFO
BLDG ELECTMF.CH
P14RMIT ISSUANCE ElEl P UMB ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
LOB DESCRIPTION
gW02 Ihereby Division amlicerBusinss and irofesions Coadr9nd(commencing with
ce Section]000)of Divixion3 of the Business and Profession Code,end my license is in PANELS ��
tty--ZF Licfailense
nse Clait setteet.
.<0- Licenu Class LIC.X IIP T0200AMPS ,
era=y Date Conmactor 201-1000 AMPS
Z OrV'nZARCHITECT'S DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA WQ.FT.
0z a I understood my plans shall he used res public records.
Q'rF-� SIGNS ELECTRICAL
Licensed Professional
9p.yW OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M1SC.
iCO2pV., 1 hereby Mr.that 1 am exempt from the Commmm's License Law for the
W 3 k m following riensmn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which require.a permitm cmnstmcq alter,improvedemolish,re repair anyslounthe
}� priomoits issuance,also requires theapplicamforsuch Permit file signed xuimment POWER DBVICCS
G O that he is licensed pursuant o the Provisions of the Contractors License Law(Chapter
a o�' 9(commencing with Section 7000)ofDivision 3 ofthe Business and Profession Cade) SWIMMING POOL ELE as
VALUATION
or that he is exemptnherefrum and the basis for the alleged exemption.Any violation of OUTLHTS-SWITC - IXTURE
,Z. Seen..7031.5 by any applicant fora permit eubjeeuithe ep,]I.,n a civil pend,,of
5Tp not more than Eva hundred Jollara($500). NEW REM ECIR RY.
tY m ❑ I,esownernOhepropcny,ormycmploywwithwagdutheinolecompemation, Q' STORKS TYPE CONSTRUCTION
a3� will do the work,andthe nructurcis not intended oroffemd forsale(See 7044,Business
and professions Cale:The Contractors License Law does not apply to an owner of
Unfairly who builds or improves thereon,and who does such week himselfor through his OCC.GROUP RFS.UNITS
own employees,provided that such improvements are not intended or offered fm sale.If,
however,the buildingor improvement is sold within one yearofcompletion,theowner- TOTAL;
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowner of Ne proper,em exclusively contracting with licensedcomoaztors to QTY. PLUMBING PERMIT FEE FLOODZO 1 APN
Lnnnuct the project(Sec.7044,Business and Professions Cade)'the Cmamea is
icense Law docs not apply toanotuneroffimpeny who buddror improvesthereon,and L PERMIT ISSUANCE
who nnnracls for such projects with acontmptarod hcemed pursuant todu Convectors
License Law. ALTER-DRAIN&VENT-WATER EA) FEE SUMMARY
❑ 1 ton exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE '1 !E
SANITARY Y—N
—
Owner Data RFCI]PT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ Thereby affirm that l have acenificem ofcarwent to self-num,or a certificate ofRECF.IPTp
Worked pens.Com tion lmuranceora unified copy thereof(Sec.3800,lab CJ which FIX'fURPS-PER TRAP PARK FEE Y—N
—
Covers all employee's under this permit. GAS.EA.SYSTEM.1 INC. OUTLETS RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS-P.A.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ Cenified copy is hereby furnished.
❑ Cenified copy ie Bled with the city inspection division. GRHASP41NDUSFRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is for one hundred dollam D000) SEWER-SANITARY-STORM EA.200 ['. ENERGY FEE
or less.)
I eerily that in )))performance frim work for which Nia permit is iuued,Iahall WATER II' /�
on
employ en m y er eo a to he euhieLla thahlbriten' PAID
O z
mum,a i alQo D f !/'!��Y WATER SYSTF.MITREATI Date Receipt If
NMI is fG
z 0 NOT[ PPLICANP If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
E-' p) become s feet to the Workers Compensation provisions of the Labor Cade,you must
� ; fonhwi comply with...h provision m this permit shut[be domed revoked. BUILDING FEE
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that there is a construction lending agency for the performance of q3 ELECTRIC FF.E
O the work for which this pemit is issued(See.3097,Civ.C.)
IY ULchli,6 NorAddy v PLUMBING FEE
Lender,Address QTY. MECHANICAL PERMIT FEF,
U 1 ecnily that 1 have road this application and suite that the above information is
4 coact, laree to coat with all cit add ordinances and state laws modin to PERM IT ISSUANCE. MECHANICAL PEE
B Pd tui yon county g
y .tans-nomlding nced oters herebspecti npourre presemuitiva nfthie city memeropon Ne
U above-me)agree propve.indrmily and mcpnxa. ALTER OR ADD TO MF.CII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino.gator
liabilities' gmemts.costsaade nseswhich may in any wayacemeagaimarratd City AIR HANDLING UNIT 1010,000 CFM)
me rte ofthe i fNis permit
G Z.- AIR HANDLING UNIT(OVER I0.000CFM)
Si sof Applicim/Cemeaetin Da EXHAUS)I IOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store m handle lmzardoue material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety II EATING UNIT(OVER 100,00)BTU) T TAE:
Code,Section 255320)7 VIiUl ION PAN(SINGLE RESID) �—
❑Yen ❑No
W ill theupplicam orfmure builJingxcupam usecquipnrtm nr devices which emit
BOILER-COMP
100,110OBTU) I ANCE AT8
amck ox it eomandium,as defined by the Bay Area Air Quality Managemern
DlstricB ROILF.R-COMP(OVER IOO,t)100.000 BTU)
❑Yee ❑No NEW RESIDENTIAL MECH.—SQ.FT. OCT
24 1994
1 have read the hazardous materials requirements under Cluiptcr 6.95 of the 1 Or �UrtH I IIvU
Californiapanf Cher&Safety Code,Sections be met 25533 and 25534. 1.Caremnd that
if the building Jos not emordtly have a atom,that it is my mponibiliry to notify the
Occupant of the requirements which nun be met prior m issuance of a Cenificam of
Occupancy.
Owner or math rizal agent Date TOTAL: ISSUED BY: