27869 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ECE'CrIUCAT, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION {•y rye-/ems /rJ1. BUILDING PRON!C'1'IDENTIFICATION -
27869
BUI�INGADDRgS. 4M P,,44 ,• V9' UNIT# LOT# gANI'1'ARY NO. APPLIG'110NSUBMITTAL DATP,
OW IIIiPPR``SIr�L,Lr/N,LASML PII NE: CON'IRA 'I'OR'S NAME: LICNO:
L • AML 401 Z - (D lO LV ILL N/C CONTROL«
ARCIII'IECT/ENGINF.F.R: LIC NO: ADDRESS: ❑
/ CONTACT: PHONE: r „; y s - - PERMIT INFO
QT.Y. , 1 ELP.CiRIC PERhJITBUILDING
- a i-F TIER , - =
--'. S: a 4 li
BLDG PLUMB f:C
PERMIT ISSUANCE � JIK�.
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL J09 DESCRIPTION
OmZ Iherehyam firthat l am licensed under pmvisionsofChapter9(cottunencingwith 11
woo Section 7")of Division 3 of the Business and Professions Code,and my limarse is in PANELS
full LnceSaid effect.
F�C� License Class Lic.# UP T0200 AMPS.<,%
may Date Contractor 201.1000 AMPS
Z~O zao— ARCHITE=S DECLARATION SQ.IT.FLOOR AREA $1SQ.FT.
OVER UX0 AMPS
OZ-0 1 understand my plans shell be used as public records. ak.s
r= SIGNS ELECTRICAL
Licensed f4oferxianal
COWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xdxO�y(J 1 hereby M.Nam exempt 1 aexempt from the Contractor's License law for the
W 3 h-an following reason.(Station 7031.5,Business and Professions Cade:Any city armory TEMP.METER OR POLE INST.
V� which requires a permit to construct,alter,improve,demolish,or repair any structure
pnarm its issuance,also requires Cheapplicuntfor such permit to file a signed statement POWER DEVICES
ty O that he is licensed p mmand 1.the provisions of the Conumcter's License Law(Chapter
a.y 9(commen' with Section of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
Ko� nog wi ) ) VALUATION
Warn or that h70315 by any therefromandfthe basis for theraegedexemption,Any violation of
> Section]I an by any ah, ant farapermit mhjects the applicant to ecivil penalty of OUTLETS-SWITCHES-FIXTURES
than Ove hundred dollars($500).
tY m wneroOhepropeny,nrmyempinyecswiNwagesastheirsolecompemeuon, NEW RFSIDP.NTIAL ELECfR _SQ.FT. STORKS TYPE CONSTRUCTION
ill do the work, it the munure isnot imended oroffemd for See(Sec.]044,Business
and Professions Code:The Contractor's License law does not only to an owner of
nspeny who builds or improves thereon,and who does such work himselfor through his
If, �1-iia' OCC.GROUI' RES.11N1'f5
employees,prmidedihm such improvememsmenotimm�dedoroffemJ formate.
however.the building mrimprovement is sold within one yearn(completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.)
❑ Lasownerol'thepmpeny,umex tvely nntractingwithlicenseJmntmcto t QTpYIy' w x PLUMBINGPERMITs y*r FEE; IS.00D ZONE APN
construct the pro" (Sec.]044 siness and afessions Code)Tic Contmetor's PERMIT ISSUANCE
License Lawdoesnorapplym erofpropert whobuildsosimprovuthereon,and
whocomesetsforsuchp is with avenoacmt(s)'censedputsunnttothe Connector's ALTER-DRAIN& -WATF;H lm)
License Law. _ FEE SUMMARY
❑ I um ase oder Sec. B&P C for this twson BACK FL PROTECT.DEVICE. OU ISD'FEES
SANITARY Y N
Ow Data RECEIPT#
WORKMAN COMP.NS NDEC RATION D S-FLOOR,ROOF,AREA,CONES, SCHOOLTAX Y N_
❑ Iherebyeturathutl ha cans fc nrtam If-insure,macenificateof 'XrfURE5-PERTRAP RECF.IPTp
Wmker%Compenm tion tomo led,ase Nerce, Sm.3800,Lb C.)wh' PARK FEE Y N_
mvenallemploye's t Sc I. GAS-FA.SYSTEM-1 INC. OUTLETS
RECEIITp
Policy# BUILDING DIVISION
Company OAS.HA.SYST'F.M-OVER 4(FA) PLANCHECK FEE
❑ Centrad co y i hereby famished.
❑ Certified col filed with the city inspection Sion. GR EASEONOUSTRI. ASTIJ INTER iPTOR GRADING FEE
CERTIFICATE OF EXE ON FROM WORKERS' GREASE TRAP SOILS FEE
COMPS ON INSURANCE
O'bi,Smile.need oat mphool ifthe permit is for one hundred dollars l$100 SITWEIKSANITAR ST EA.2( ENERGY IEC
leu.)
I cenify tl a performance ofthe work forwhich this permit is issued.)shall WA T:R
Inyany person in any mamar so as to become subject m the Workers I PAID
Compensation laws of Califomiu. Date WATER Y EM/L' p N Date Receipt«
O z Applicant
z C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RFS IAL PLM .FT. TOTAL:
p l� became subject to the Worker's Comperead an provisions of the Labor Code,you most as
forthwith comply with such provisions or this pmoul shall he ds:emed revoked. BUILDING RE aha
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that Nem is a construction lending agency for the performance of TOTAL: ELECTRIC RE
C) the work for which this permit is issued(Sec.309],civ.C.)
Lmdecv Name 5
0 U Lender s Address Q'rl': yMEC- NICAI PERMIT. : i FEE PLUMBING RE
1 cenify the I have modulus application and state that the above information s uta
Gw.. PE
correct.I agree to comply with all city and county ordirmnces,and sate laws relating to N DANCE MECHANICAL FEE
building corm ucio n,and hereby authorize representatives ofthis city toenter upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purai AL9'ERORADDTOMECH.
(We)agree to save,indemnify add keep hmmlwi the City of Cupertino against
IndilitiesJudgments.costs and expenses whit may in my way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
e the gtanungipf thisa AIR HANDLING UNIT(OVER 10.000 CFM)
3Z�
Signa ApplicnnVQrmmnor Dm EXHAUST HOLD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(M IW,M)BTU) Date Receipt
Will the applicant or future building occupant mare or handle hamalaus material
as dby Nsi
o Cupano Munlclpal Cale,Chapter 9,12,and the Health and Safety
BEATINGTING UNIT(OVER 100.00 BTU) T '
Code.Sec&coon 25532(a)1
❑Yes El No VENTILATION PAN(SINGLE RESID)
Will the applicant or future building nccupantuseequipmenmrdeviceswhich emit BOILER-COMP(JHPOR 100.000 BTU)
ISSUANCE DATE
hnzmda,air conwntimms as defused by the Bay Area Air Quality Management BOILER-COMP(OVER PULW)B'TU)
District!
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT. �#.r
I have read the hazardous materials requirements under Chapter 6.95 of the - MAR K !/ 1995
California Health&Sufay Code,Seedons 25505,25533 and 25534. 1 understand that C17 Y ser
Hthe building does a
not currently have a read,that it is my responsibility to notify the UUjjL
..punt of the requirements which mast he met prior m issuance of a Certificate of
acupancy.
Owneror null nzcd agent Date ISSUEDBY: