27219 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB,157NI7-ELEC I R PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDEN'1'INICA-1'[ON 27219
1 BUILDING ADDRESS: y SANITARY NO. APPLICATIONSUBMITTALDATE
_Q0,361 VI Q- 4a-l UNIT p tp r � LOT X
OW
LA.
PHONE CONTRACT SNAM17: LIC NO:LNIC CONTROL#
a7�/ flares 'CA 98s•6om ctvns^
• ARCHII'EC'1'/ENGINFER: .IC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT PER ED ELECT
PERMIT INFO
ee C apo er !!Ef ! 4061 PERMIT ISSUANCE BLDQ ELECT PLUMB MECIL
LICENSED C NTRACI'OWS DE CIA TION APPLIANCES-RESIDENTIAL K�SJ{ I�OyBI{DESCRIPI�A'IjJOpN
QWz I lorebynlfum that l em licensdundttpravuiomo(Chapter9(cotmncncingwith
Fd 00 Section 7000)of Division 3 of the Business and Professions Can.sod my license is in PANELS
Q License Class LiaX UP T0200"PS v (�
y 6 vp'i Dae Contractor 201-1000 AMPS
I"vOs ZK ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
Z O y oz- 1 understand my plans shell be used na puhtic records. OVER 1000 AMPS S6
® SIGNS ELECTRICAL
K U Licensed Professional OWNER BUILDER DECLARATION SPECIAL CIRCUTOMISC.
nOaI hereby affirm Na 1 as exempt from the Convocmr's License Law for the
PF. following reason.(Seetion 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE FIST.
f�y which requires a Pemba to construct aper,improve,arnwtish,or repaM1 any stmemre
NYS prior to its issuance,also requires the applicant(orsuch permit o file asigned statement POWER DEVICES
� �p rhes he is licrnsed Pursuenno the provisions of the Conlncmra License law(Chapter
d&'e� 9(commencing with Section]000)afDiviaionJofthe business and Profession Code) SWIMMING POOL ELECTRIC VALUATION
othat hei31.5bynhemfromntfthe basis fonhensegeaexemption.
toAny ivilpenaltyon of OUTLETS-SWITCHES-FIXTURES a/6 any,
tZi Sat a as
troyapplicantd.11. $permit subjects the applicant toacivilpmelry of
at more than five hundred deltas(5500), NEW RESIDENTIAL ELECTR _SQ.FT.
K�Q
ye ❑ Lthewrk.modeestructy,armyemtendaJswiNwegesavtheinole compensation. STORIES TYPE CONSTRUCTION
am will do@cwons end the he Corciatoaimm�aedor ffered Law
rot apply to a Business
and Professions Code:The Contractors I.icene Lew does not apply to an owner ofis
properywyess,pasorimprovachimprveramsdaessuch wohhimulfor through his OCC.GROUP REg.UNITS .
ownemployees,proviced that suchimpmv sold
wit artnot fended moffered fmsWe.IL
budder wNeave the burden uf,mentishat he within one yeaofcaponve om Nemwmer. TOTAL: X
builder will have the burden of proving Nm he did not build or improve for putpau of
sole).
❑ I,ns own<roftheproperty,amexdusircly convecting with licenuJ cono-ecmm to QTY. PLUMBINGPERMIT FF-E ILOOD ZONE APN
construct the project(Sec.7044.Business and Professions Code:)The Characters PERMIT ISSUANCE
License law method apply manownerof propa y whoadhisor improvesthereon,and
Who mmrecas for such Projects with acontractor(s)licensed pursuanuotbe ConuncmFs ALTER (FA)
License Taw, FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this arson BACK FLOW PROTECT,DEVICEID
Y Y N
Owner Ilam
DRAINS-FLOOH,ROOP,AMA,COND, RECEIPTp
WORKMAN COMPENSATION DECfARAT1ON SC OOL ASIS+ Y N
❑ Ihmebyaff'batt haveaani0cme ofconertua ulGinsure,ore ccrti0wm of RECEIPT#
Workeri Com nsatia lnumnceora crdifedc FlXTURES-PER TRAP
pe spy 0ermf(Sec.3gOB,Iab CJ which PARK FEE Y N
covers all employee's under Wis pepnit. RECEIPT p GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy X BUILDING DIVISION FEES
1 Company GAS-PA.SYSTEM-OVER 4(EA) PLANCIIECK ME �—
❑ Caiiedcayishercbyfumislam.
❑ Certified copy is filed with theciry inspection division. GREASEANDUSTRLWASTEINTF.RCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need a,be completed if Ne permit is Parona hundrddolhrs(51001 SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or I..)
I cenify that in the performance of the work for which this permit is issued,)shall WATER HEATER W/VENT/ELECI'R
not employ any pemon in my manner sat as to become subject to the Workers' PAID
Compensation Lawsof Califomia. Dam WATER SYSTEM)TREATING Dam Receipt
Q Z Applicant
7P0 NOT ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PWII. SQ,FT. TOTAL:
F^ U) bsanme Subject to the Worker's Compensation provisions of the Labor Code,you must
j forthwith comply with such provisions.,,his permit shall be deemed mvokm. BUILDING FEF. // a
w C• CONSTRUCTION LENDING AGENCY SEISMIC FEE # 7D
z
^a I hereby affion that there is a construction lending agency for the performance of TOTAL: ELECTRIC FET:
J O No work far which this permit is issued(Sm.3097.Civ.C.) a V p
Lender's Name
(tender's3#
U AJdAddressPLUMBING FEE
Address QTY, MECHANICAL PERMIT FEE s'p
I cenify,Nat 1 have rad this city
and county
and stain aha a aboveawsadmit,is /
H-1 correct lugrce to comply with all city and county ordinances ad area laws mlatingm PERMIT ISSUANCIi MECHANICAL FEE O J
building eastructum,a ll hereby authorize mpmmadivesofthadry waterupotahe CONSTRUCTION TAX 3 S
1 V 7-. above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
linbili0es,judgments,cosm mdexpenses which may in any wayacerm against said City AIR HANDLING UNIT 010,000 CFM)
in conk 'c of the grunting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature wl'ApplicanducalcuItor Dam EXHAUST HOOD(W/DUCT) PAID
I IAZARDOUS MA RIALS DISCLOSURE HEATING UNIT(TO I W.W BTU) Dam Receipt
Will the applicant or future building occupam store or handle hamrdous material IIFATING UNIT(OVER IOO,aNp BTU) TOTAL:
as definrl by the Cupertino Municipal Code,Chapter 9.12,and the Health and Salery /
Cade,Section 255J2(g1
E3 Yea ❑Na VENTILATION FAN(SING LE RPSID) 14
BOILER-COMP UHP OR B)B,"BTU) ISSUANCE,DATE
Will air co applicant rasa building occupe Bay Arm Aen Quality es
s
District? air conmminanm as defined by Ne Bey Mea Air Qoeliry Managemcm BOILER-COMP(OVER IW,000BTU) -410
District?
❑Ycs Cl No NEW RESIDENTIAL MECH.—SQ.FT.
I have mad the hazandous materials requiremems under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. I understand that
if the building docs not currently have a tcnmt that it is an,responsibility ar nmify the
cer pun of the requirements which must be met prior m issuance of a Certificme of eLUrCa M/
Omcy.
' Ownerwoc'or authorized agent Date TOTAL: ISSUED BY:
OFFICE