27846 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 8 A
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION [{
BUILDING ADDRESS: //�� /� SANITARY NO. APPLICA'TONN SUBMITTAL DATE
40 37 CR, 1 �//a UNITN 112//f _(—LOTN 06 Q q
OW RS NAME: �/ PHONE CONTRA R'S NAME: LIC NO: N� CONTROL#
- af:en �on$GS 9FlS''(DOO � er
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
'F— C//f /� C ^ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
� GP OIG'- 5^ 0 66 BLDG ELECT PLUMB MECH
PERMIT ISSUANCE x x 9 9
LICENSED ONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL Id JOOBIDESCRIPION 161
pay Thereby affil vision I alicensed ine Business
n'Poionsiona Core, (cnmmareff,cense with
u10 Section100i
and effect. an3of tits Business and Professions Cada anJ my license is in PANELS ���
FF- I
f�Z full force I-11 elTecl.
Z License Class Lic.N UP T02W AMPS
inDy
Data Coclm,a 20I-TWO AMPS
z0an ARCHITECTS DECLARATION OVER IWOAMPS SQ.PT.FLOOR AREA $/SQ.FT.
1 understand my plans shall be used as public records. " O
SIGNS ELECTRICAL
My�y'' � h¢enseJ professional
�Oa< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. n(
V I hereby affirm that I an exempt frem the Convenor's License Law for the A
tali kO vFi following reason.(Section]031A Business and Professions Code:Any city arcornI TEMP.METER OR POLE INST.
f5 w.a4 which requires a Permit 10 continuum,altar,improve,demolish,or repair any structure
r°a� Pdur to its issuance,also requires the applicant for.cuch Permit o file asigned statement POWER DEVICES
O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
4p1+. 9(commencing with Section/000)ofiivislon 3 oftha Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that yYjZ Section 703
exempuyapplimand the basPermit subjects
the
dexemptt to civiny l
of J 6O
`Q Sermon-031.5 by handle dollrs($50rmitsubjects the applicammacivil penelry of OUTLETS-SWITCHES-FIXTURES
mnot more then five hundred dollars($500). NEWRESTDENTIALELECTR _SQ.FT.
❑ I,usowneroflhepropeny,ormycmployaswith wageeastheirsolecompensetion, STORIES TYPE CONSTRUCTION
q will dothe work,andthe structure is not immrdedoroffered fur sale(Sec.J(144,Bminess
and Professions Code:The Contractor's License Law does not apply m an owner of
progeny who builds mimprovesthereon,andwhodoessuch work hlmselfonhmughhis
own employees,powided thatsuchimpusamentsam not dandedorofEred fortait,If, OCG GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for poryoee of
sale.).
❑ I,asownerofthepmpeny,amexclusivelycontractingwhhlicense emmetorsm QTY, PLUMBING PERMIT FEE FLOO_ZONE APN
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's
License Law does not apply to an ownerofpropeny who builds or improves thereon,and PERMITISSUANCE
who contracts for such projects with a conumctar(s)licensed permanent to the Contractor's
License Law. pLTER-
DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
• Owner Dam DRAINS-FLOOR,RODE,AREA,COND. RECEfPTN
WORKMAN COMPENSATION DECLARATION. SCHOOL TAX Y N
❑ Thereby affirm thatlhave acertifoa¢o[Consent to self-manne,macim fieneof ITXTDRE3-PER TRAP RECEIPT
Wotif
rkers'Compensation Insurance or a ccred copythereof(Sce.3800,Lab C.)which PARK FEE Y N
coversall employee's under Nis permit/ GAS-FA.SYSTEM-1 INC.4 OUTLETS
CRECF.IIT N
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) / PLANCIIECK FEE O
❑ Certified copy is hereby famished. �
❑ Certified ropy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER SANITARY-STORM EA.200FT. ENERGY ME
orle".)
I ecnify that in the pentmarmnceofihe walk for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
O z Compensation Lawsof Cnlifomia. Data WATER SYSTEM/1'REATING
Applicant Date Receipt is
z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
V] become subject1.the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE /D d/
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE III r�
Z I hereby affirm thatthere is a construction lending agency for the performance of
V Othe work for which this permit is issued(Sec.3091,Ci,C.) TOTAL: ELECTRIC FEE
Undoes Name 71
,��
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
Lka I certify that 1 have read this application and stain that an above information is MECHANICAL FEE /0.72
coining lagree mon,comply
and herM1all anthoorty countyordinancesofandcity to ws enter
gw PERMIT ISSUANCE
Z abovengootioned proper herebyaection purposes.
Lives of this cirymenter upon the
V 'zr above-mentioned propee,inde indemnify
inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX 6
(We)agree m save I Intlemnify and keep awyntas the City of Cupertino against
liabilitics,judmetns,costs undexpenseswhichmey in any way accrue against sold City AIR HANDLING UNIT(TO 10,00 CFM) aJ✓ /
qua of Nag ngohhis permit.
HIM
AIR HANDLING UNIT(OVER IO,IXq CPM)
mea LL�
Stg ureoi Appbwnt/Cmdoi r / / /Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IWJWO BTU) Date ReceiptN
Will the applicant or future building occupant store or handle hazardous material
as defined by the Calandra Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOQOW BTU) TOTAL:
Code,Section 25532(e)'t
11 Yes 11 No VENTILATION PAN(SINGLE RESID) OOaB�
BOILER-COMP(3HP OR IW,WO BTU) DOT
C1qEoDAaaT��E
• WJllheaconta contaminants
tsar defined
by the Day Area
igemech it DOT U 1995
hmardous air conwminants as JeBred by the Buy Area Air Quality Management BOILER.COMP(OVER 100,000 BTU)
District' ❑Yes ❑No
NEW RESIDENTIAL MECH. SQ,FT. CIIy f i WrLH I'INO
I have read the hazardous materials requirements under Chapter understand
of the fI
California Health&Safety Code,Sections 25505,25533 and 25534,a I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
c pant of A requirement which must be at prior m issuance of a Cenifrma of
Occupgp
cu " '- —a�� 9� TOTAL: ISSUEDBY:';\\'�
Own authonzed agent Nt / Dam
OFFICE