27755 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IAT, PERMIT No.
APPLICATION/PERMIT PIDMBING-MNIDENTIFIC 27755 f 7 [ C
BUILDING DIVISION IIUILIIING PROIRC'I'IIIEN'fIFIf,A'1'ION G r JJ
1 RUILDING ADDRESS SANITARY
^1�`—``11^ SANITARY NO. APPLICATION SUBMITTAL DATE
O��` a#. wDDNIT# LOT /—�� L
U li PHONE: CO /kC'O 'S NAME: `LIC NO: N/C fCCOONTTRRO/L#
ItClIII'IiCT/ENGINEER: LICNO: A RES ; ❑
ONO ACT: PHONE: ' '- i ''' -S+' ` ,BUILDING PERMIT INFO
QTY r q ��A iCTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
TOB DESCRII9'ION
Qwz I hereby affirm that l am licensed under provisions of Chapter 9(commencing with
POO Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
C Z� full force and effect.
F License Class Lic.p UP T02W AMPS
m<y Mule Contractor 201-1000 AMPS
zOyZ" ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR ARIA $/SQ.IT.
OZ-'@ 1 undersand my plans shall be used as public records.
y SIGNS ELECTRICAL
oe, Licensed Professional
K
d'< OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOw I hereby affirm that I sm exempt from the Commaors License Law for Be
Bw':tA fallowing on.(Seed'n 7031.5,Business and Professions Code:Any city or county TEMP.MLTC•R OR POLE MST.
F�y2 which issuance,
unpertso requires teappliq improve,h poorat Or¢pairanyswcare
M0 thiorbitsicensed pursuant
requires theapplicantforsuchCo pertniva fileaseLaJ statement POWER DEVICES
<Op Q(con iencemodpi Section
uathe provisions of the COmador'sardPse Law(Chapter
0.0.oC 9(eommeisexemit therefrom
AKKOof Division 3oftheed exemptio ,AnyvionsCode) SWIMMING POOL ELECTRIC VALUATION
iW_rn Sethoat belaexbysa erefromandthe Perbasmitonhets eJexemptt to civil parolt,of aa��....��
F 6
act
ne than bye addredidollrs($50T.iuuhjaa[he applicant civil penalty of OUTLETS-SWITCHES-PIXTIIRgj {/.;I���y��
not marcthanfivehepro dollars($50T. „/(��4/
y� � ❑ I,usownerOfNeprti n NEW RESIDENTIAL ELECfRpctumis nempl0yedmiNwegesaaide(Sec.c044,Business STORIES TYPE.CONSTRUCTION
3— will dalhework,andthehe Co amerce Licenstir Law
dosead not apply
to an owner
of
and Professions Cade:The COntrecmrs License Ww docs not apply m ea owner of
property wyees,pdsorimproves hat sucM1 improve who docssuch workhimselfe forradhhis
cmployaspmS.,inarwchimpmvemewarenayearof completion
ftirsala B, OCC.GROUP RES.UNITS
howcvcp the have
the bar improvement is sold within oneyca orimprove for the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
a❑ll Is emfthepmperty,our exclusively contracting with license(]contacto I Q7�Y%:a1� PLUMBING j$RMI• ' - FLOOD ZONE APN
mase Ihonproject(Sec.91W4,Business and Professions Codprove Coma,said
License Law Joos notapplya an with acowderof property
mmetors)whobe purse pursuant
to the thereon,said PF,RMI'f ISSUANCE
whenseaw.for such projects withaconrvemr(s)Iiceasedpursunnua the Comacmr's ALTER-DRAIN&VFM-WATER
License Law. (FA) PCE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
Owner Dale RY Y_N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,CON R[CLIPI'#
AmokSCI1001.TA% Y�C N
❑ Iherebyaffirm thetlhavm Certifies¢afconsemmsdf-insure,on arifcam of FIXTURES-PER TRAP RGCIi1Pl'#
Workenf Compensation insurance uracertifiM copy tbercof(Sa.lgfq,LabCJ which PARK FEE Y_N
covers all employee's coder this permit. GAS-F.A.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Ctimpoay GAS-HA.SYSTEM-OVER 4DA
ElCcrtifele.r.tisherebyfrmished. (' ) PLANCIIECK FEE
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
GERTIFICATE OF E%EMPDON FROM WORKERS' GREASETRAP SOILS ITE
COMPENSATION INSURANCE
fnissection nod nm be completed if the permit is for one hundred dollars(1100) SEWER-SANITARY-STORM EA.2NIFF. ENERGY ITE
orless)
I certify that in the perfomanceof the work for which this permit is issued,I shall WATER I IEATER W/VENT/ELECTR
not employ any person in any manner w as in become subject m the Work. PAID
Comprraainn Lawscf Cnlifomia. [)are WATERSYSTEM,'MEATING Date Receipt#
Q Z APPllcum
7r 2 NO HCH PO APPLICANT:IL after making this Certificate of Exemption,youshould NEW RESIDENTIAL PLMB. SQ FT. 'TO'T'AL:
E' (q become subject o the Worker's Compensation provisions of the Labor Code,you must
jforthwith comply with such Provisions or this permit shall be deemed evoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SIHSMIC ITE
D 2I hereby affirm that hem is a consometion lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(See309].Civ.C.)
I<nders Name PLUMBING FEE
Ou-' Lenders Address QTY,r ' MECIIANICAL PERMI'P : `FEE,
U I certify that 1 have real this application and se that the above information ' '
p+.W rsncct. lu6matttm,it dwlih all Illy avJ county ordinanwseod smmientrelainglti PBRMI'T ISSUANCE MECHANICAL FEE
rF) Z above-mentioned
timand caby utooriurePmsenativetof this city loemer upon the CONRIRUCTIONTAX
Uz above-mentioned prop for' . Ginn purposes. ALTEROR AUDTO MECH.
lLeSo agree m y and kap harmless the City of Cupertino against
liebilitics,judgm swhich may in any way accrucegainst said City AIR HANDLING UNIT('1'010,(KKI CFM)
in van sequen t Permit.
L_L �` AIR HANDLING UNIT(OVER 10,1)(10 CFM)
Signal Applicant/C a Deo E%HAUST HOOD(W/DUCT)
PAID
4 ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO FILM BTU) Date Receipt#
Will the applicant or future building occupant store or handle hcxardnus material ❑EATING UNIT(OVER 100,000 BI U) T I'
m Jefned by the Cupertino Municipal Code,Chapter 9.12,end the Ileulth and Safety
Cede,Section 25532(x)7 VENTILATION FAN(SINGLE RMIDI
❑Yes ❑No
Will theapplicantorfwore buildingaccupant useequipmentordevices which emit
BOILER.COMP(3HPOR HA.000BTU) ISSUANCE DATE
uanlous air contaminants as defined by the Bay Area Air Quality Management
BOILER-COMP(OVER 100,000 BTU)
Istria'! q
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. P w
L"I'd,
ave read the humidities materials requirements under Chapter 6.95 of the �� 410 -
Ilgath&Safety Coda Sections 25505,25533 and 25534. I unJernend that e
ing does not currently have a tenam,that it is my responnibil ity to notify the af the requirements which nmxl be met prior m issuance of a Certificate ofy.r aathodmd agent
Date TOTAL: ISSUED BY: VW�I
OFFICE