27854 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD
L LL BI A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27854
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMGTTALD'AM
,Q0376 Vi'a kldtm UNIT# L.n .�`LUT / /6 _ .
OWN RS AME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL# {^��
i mI'ian Dine 9�S- 00 w er
ARCHIM47VENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
1 e e Q C //� �f p (y QTY. ELECTRIC PERMIT FEE
( V OO iq r l/O —90sPERMIT ISSUANCE BLDG ELECT PLUMB MIiCH
IgFJ� a(
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL R If pd{ IrNsLOB DESCRIPTION
qay I hembyaffrmthat l ren licensedunder provisiorenfChapenticommencingwith
bE ml for 7000).f of Dlvlsinn9of the Business and Profesxions Coda,and my license is In PANELS /'�� ��
F tEJ full force and Effect. UP TD 200AMPS /
ZZ LLWT License Class Lic.x
vFiQN
7O, Data Conn." 201-1000 AMPS SQ.FT.FLOOR AREA 5/SQ.IT.
Z ARCHITECTS DECLARATION OVER 11%10 AMPS
OZ—❑ understand my plansskull heusedus public records.
4Ft.� 935-6
Licensed Profcasiowl SIGNS ELECTRICAL 5 6
Ey,KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOaU 1 hereby affirm that I em exempt farm the Contractors Licence Lew for she
1y34.y following mason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
J=Lfa which requires u permit m construct,cher,improve,demolish,m repair any atrunurc
N� prion.its issuance,elm requires theepplicam fmm,hpe.is1.Gleasignednmemeat POWER DEVICES
yl .p that he is licensed pursuunuo the Provisions of the Contractors License Law(Chapter 2X o�' 9(conmeaoing with Section]000)of Divisim 3 oldie Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_,y or he is exempt therefrom and she basis for the alleged exemption.Any violation of OUTLETS-SWITCHLS-FlXTURES O
Z 4 Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of / #�/#
not more than rive hundred d.11ass($500). ,�
m�o ❑ LasownernRhe property,ormyemployees with wagesmtheirsolecompensation, NEWRFSIDENTIALELECfR _SQ.FT. STORIES TYPCONSTRUCION
y3— will do the work.and the structure is not ntended or offered for sule(Sec.9044.Business
and Profess ns Cute:The Contmmora License Law does not apply to an owner of
property whobuilds Or improves thereon,andwhodoessuch workhimselfonhroughhis OCC.GROUP RES.UNITS
own employees,provided Na sac h i mpmvcmcnts are not imended or offered for sole.If,
howevenshe building.,improvement is sold within one year orcompletion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ I,asnwneroftheFoNny,amexclusivdycontractingwishlicenudcontmetorst. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(See.7044.Business and Professions Cale:)The Contractors
License Law does not apply to an owner ofpmpany who builds or improves thereon.and PERMIT ISSUANCE
who contracts for such projects with aamtraarr(s)licensed pursuant n the Contractor's ALTER FEE SUMMARY
License Lew. (A)
❑ I am exempt under Sec. ,p&P C for this mason BACK FLOW PROTECT.DEV ICL O ID.IVES
ANITARY YN_
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,ARFA,COND.
WORKMAN COMPENSATION DECLARATION S COL TAX Y N
❑ sma'Co affrmthat lhave
rance ora catteofc copy nt the ul6instue,or Ub C.)cur.fwhich RECFIPI'#
FIXTURES-PER TRAP
Workers'Compensmion Insurance oraeenified copy hertof(Sec.JB(p,lab C.)which PARK FEE YN
covers all employee's muter this permit. GAS O -HY SYSTEM-1 INC. OUTLETS RF.CBIPf#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
'- C1Certified copy is hereby fumished. eGCi
I11 ❑ Cenifedmpy is filed with the city inspection division. GRGSEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2(#)FT. ENERGY ME
or less.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER I(EATER W/VFNIYELECIR
not employ any Person in any manner so as to become subject to the Workers PAID
Competsationlawsof California. Dam WATER SYSTEKMEATING Date Romig,#
Applicant
NOTICE TO APPLICANT:If,Whe,makingshis Canifico¢of Exemption,you should NEW RESI DENTIAL PLMB. SQ.FT. TOTAL:
F^ (q tamome subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit shall4 deemed revoked. BUILDING FEE1/7
#I
A CONSTRUCTION LENDING AGENCY SEISMIC IEE 4'O
I hereby affirm that chase is a construction lending agency for Ne performance of TOTAL: ELECTRIC FEE (mss
U 0 the work for which this Permit is issued(Sec,309'/,Civ.CJ J,y pD
OFF--�t leader's Nume
P-� 1-rndcr's A=. QTY, MECHANICAL PIiRMIT FEEPLUMBING FEE
V I certify that I have read this application and state that the above information is MECHANICAL FEE
contact. PERMIT ISSUANCE JJ 18'3,Da V 8
legree to comDlY wiOh ell city and county ordinances and smtc laws rcla0ng so
rte. to building construction,and hereby authorize representatives of this city mentermars the CONSTRUCTIONTAX
V Z above-mentioned property for inspection proposes. ALTER OR ADDTO NIECE,
(We)egrc�qrm save,indemnify end keep hmmlcv he City of Cupertino against
liubilitiea,ju s6rents,costsundexpcnsee which may in my way acme against said City AIR HANDLING UNIT(TO Ill."CIN)
in conse% ce of the gran' this permit.
/n' . AIR HANDLING UNIT(OVER 10,000 CFM)
v
Signawm of ApplicmVConlrect Dem EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store m handle hazardous matedW
us defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HFATfNG UNIT(OVER I WOW BTU) TOTA ; #
Cale,Section 25532(.)9
11 Yes ❑No '11VENLATION PAN(SINGLE RESID) E`
ISSIJ.ANCE DATE
WilHhc applicant orfumrcbuildingoccupmtuuequipmem ord<vices whichemit BOILER-COMP(3HP OR 100.000 BTU) �� (.r� B
hazardous air contaminants as defined by the Bay Arm Air Quality Management BOILER-COMP(OVER IOO,WO BTU) ® P
Donato? C
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. 7. 9 .a
I lasso read the hazardous materials requirements under Chapter 6.95 of the r99
CalilmnHea &Safety Code,Sections 25505.255]]and 25534. Iundemand that
if the hulldin Des nm cane sly hnvcumnmL that it is my responsibility to notify the t
rccupam she requires which must be met prior to issuance of Ci,plicale of
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFIC