27957 (2) APPLICANT TO FILL IN INFORMATION WITHIN REO.LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOBD¢.MIs=RLM I XICAl. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI. n�A C
;BUILDING PRI/JEC7LIDEN IFICAI]ONf " G J J
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
0UNIT# LOT#
OWN S N ME: PHONE: C NTRACTOR'S NAME: LIC NO: Qj
N/C CONTROL r-
aRCHITHCT/ENGI SER: LIC NO: A�RE5.5 ,y 'TNF
CONTACT: d PHONE: 'btu".i -.iM�#'*' « t I r r i'( "' I_ 4 k k EUILDINO PERMIT.INFO
24 4,g wa ELECTRIC PERMIT,'y # l EE
BLDG ELECT PI.LIM71 �i
PERMIT ISSUANCE 0 jLJJ
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB CRIPTION
P02ncitz Thereby efMivisim 3 ofthnsedinssandfisionsions Cod,and(commencing with
�d00 Section 7000)of Division3 ofshe Business and Professions Cale,end my license is in pprygLg
W�«�-'-.. full force arta of I
FZIy License Ia - '� Lia# 3��,3✓oi UP TO 200 AMPS
m Q y Date Contractor 201-IM AMPS
FO ti Z,y ARCIIITELTS DCCIARATION OVER 1000 AMPS SQ.FT.FL CA E/SQ.FT.
Oz�-'q I understand my plans shall be,used as public records.
SIGNS ELECTRICAL
Licensed Pro[easional
0.
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
iC O a"1 1 ngreM1y affirm that 1 am exempt from the CanasCo License Law Ermine 1
W 3 O w following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST. • /` 7�
which requires a permit to chess the,alma improve,demolish,or mesh any atruntme [ J
°aye pathos licensed pamo requires shevisio forsuchthe Co permits License
La statement POWER DEVICES
Thatheis ticensedpSectiotothe provisionsof the Ce Basins License Law(Chapter -
W 9 ,bar heis
c. with Section a Division Softhe Business and Professions Code SWIMMING POOL ELECTRIC
(commencing )o ) /xA,UA'[LON
Sectio 7031. by yapplimand the Road, the
exemption Any civil Penalty
of OUTLETS-SWITCHES-FIXTURES I
I. N
act
than
hundred
dollars($nt for a 500).
subjects the applicem[oacivil penalty of ���I _
'ay Q n mora[hon five hondmA dollars($500) r'fl 1,
t_
uu�l m n❑ 1,asownerofthepropeny,ormyempinyeeswith wngesas[heirsole campenarnom, NEW RPSIDENTIAL ELECTR _SQ.FT. STORIES �IYYPECONSTRUCTION
p, will dome work,and the structure isamintended oroffered forsale(Sea 7044,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
property whobrlldsorimproves thereogand whoduce such workhimselforthmugh his OCC.GROUP EA
own employees,provided thin such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one yearof completion,the owner- TOTAL:
builder will have the burden ofteoving that he did not build or improve for purpose of
sale) nR; P�ehxaa.#" e - .a
❑ I,as ropho propeny,amenclus velywntrecang with licensed convectors to QTY: %$a aPLUMBINO PERMIT sS:e ran i#yPEE` ,a
FLOOD ZONE
t - £baa n3-.s ,;Z f
construct the nproject(See.7044,Business and Professions Cale:)The Contractors
License Law docanotapply man ownerofproperty,whobuildsorimpeavesthereon,and PERMIT ISSUANCE
who contracts forsuch projects with acontractial licensed pursuantlotheContractors ALTER,DRAIN WATER LA Si 3 ::f « "
License Law. (' ) t ;s y[?GL+SUMMARY; -
❑ 1 am exempt under Sec. ,B or P C for this reason BACK FLOW PIR 2;e
VICE ON'SID FEES
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOG OP, ,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers'Co affinnon Insurance
rtificamor cnnsemmarf(Snsure,0,Lab C.)which FIXTURES-PER TRAP RECEIPTIf
Workers'Campcnsatlon lneurenca oracenifled copy thereof(Sec.3g00,Lab C.)which PARK PEE YN
covers all emulav 'syn;th'p c BUILDING DIVISION PgES
Policy# .!/LSC SHOP-O/ GA S-G.SYSTEM-I TLET
Canapany�ce/e5rq �j-_.p�,p- GAS-FA.SYSTEM-OVFR4 012a, PLANCHECK HE
Certified copy is hereby fumis6ed.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTP. GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is because hundred dollars(SUXB SEWER-SANITARY-STORM EA.201 ENERGY PER
orlesa)
I certify Mat in the performance fshe work for which this .I,is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any manner out as to become subject to the Workers' PAID
Camputead nLawsaf Califomim Data WATER SYSTEM/TREATING pate Receipt It
Z Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLACE. SQ.FT. - TOTAL:
became subject to the Worker's Compensation provisions of the labor Code,you muss
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING HE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for she performance of TOTAL: ELECTRIC FEF.
O the work for which this Permit Is issued(Sec.3097,Civ.CJ
H
Lenders Name rs 4 r"k".# s « PLUMBING FEE
k' [^'
Lander',Address QTY ,s p /MGCHANICAL PERMIT'y °rFLE+..
U 1 cemtfy that I have read this application and state that the above mformeaon s e SU N
r�" 4 conrem.lagree mcomply with all city and county ordinances and state laws rcladngm PERMIT ISSUANCE MECHANICAI.
building construction,and hereby audience representativesaflhis city to catenation the
U 4 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way aeeme against said City AIR HANDLING UNIT(TO 10,000 CPM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicant/Contmnor Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO 100,000 BTU) Data Rxcipt#
Will the applicant or future hui lding occupant ems or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Creatine Municipal Cede,Chapter 9.12,and the Health and Safety
Coda Section 25532(n)'1
1:1255Yes El No VENTILATION FAN(SINGLE RESID)
Will the applicantorfme bulhlingocerpanl maequipmem ordovlceswhlchemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
ur
Instant air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
Districr9
❑Yes ❑No NEW RNTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Heaph @ Safety Code,Sections 25505,25533 evil 25534. I understand that �'-
if the building does not currently have a tenant,that it Is my responsibility to notify the
occupant or the minuteman,which most be met pdor to issuance of a Cenificam of
OCLvpnncy. '
Owner m null arized agent Dam TOT ISSUED BY: