27830 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILUIN.-F.IECHA RICAL PERMIT NO. 27830���O
APPLICATIONIPERMIT PING PROGCT IDENNIFIC L
ISUILDING DIVISION BUILDING PROIEC'1'tUP.NI'IRICATIUN
BUILDING ADDRESS: SANITARY NO. APPLCATIONSUBMOTALkIE
t7ry ✓/aa.-par
-to:�jal0 UNITM JaI
LOTM U
O FRS NAME1 CONTRACTOR'S N F:: LIC NO: •J
QL-/-1��?� D• 7 tys 4100-- n NIC CONTRO #
ARCIIITECf/ENGINEER: LIC O: Y+ ADDRESS: ❑
CONTACT: ss PHONE: QTY. ELECTRIC PERMIT FEE BU
// ILDING PERMIT INFO
Lo Q V �/✓ r PERMIT ISSUANCE BLDG IiLECf PLUMB M/Ecti
yQUVZI C LI
CFNSEDCON RACTODECLARATION
APPLIANCES-RESIDENTIAL JOB DESCRIPTION 10Iheubyafftlamlicenxdunovisimo.Capter9(cme
-00 ofDivi,ioJofthe Business add Prrofnsiom Cuteandm,fivmsei,ar PANELS
but Ieand cffmt.
License Class Lic.# UPT020AMP5 srl) 601,
N=y Date Contractor 201-1010 AMPS
ZOyZ ARCA 11111=51 DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
OVER I000 AMPS ��
OZ—p I understand my plans shall be maxi aspublic recaah.
17.yF, SIGNS ELECTRICAL
Qy�J Licensed Professional
KKK¢ OWNER-BUILDER Tam the CouTION SPECIAL CIRCUIT/MISC.
ON I hereby affirm that I an exempt from the Cnsiono o e:Any Law for the l
3 te-m following reason(Section 7031.5.flusiness and Professions Cale:Any city or county TEMP.METER OR POLE INST. `
F Ei�; which requires a#Catarina construct,Nlcr,improve,demolish,or repay any atncturc
Sod}n prior to its issace,ulsorequimsthe appliepm formes pe mai to fileasigned nmmmeot POWER DEVICES
O that he is licensed pursuant the provisions of the Conlnetols License Law(Clupter
9(commencing with Section 7000)of Division 3 of the Business and Professions Cafe) SWIMMING POOL ELECTRIC 7 VALUATION
W!2,, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
LKT Section 7031.5 by any applicant for a perit msubjects the applicantto acivil Finally OUTLETS-
of SWITCHES-MIXTURES 0
2 < not more than five hundred dollars(S50)). NEW RFSNENTIAI.ELECTR SQ.FT.
IY p ❑ I,mownerofNcpmperty.ormyempioyees wiNweg<autheirsolemmpenntion, STORIES TYPECONSIRUCTION
It. will do the work.and the structure is no,intended oraffered for sale(Sec.Rkq Business
and Pmfessinns Code:The Contractor's License Law does not apply m an owner of
pmpcny whobuildmrimpmvathercon,undwhodoessuch work himulfnrNroughhf, OCC.GROUP RES.UNITS
wn employees,pfovidul thatsuch ent is sold
wit are not tmentlN moffered forsale.If,
however,the have
the bur improvement is hath within one yemo,improve
for theownen- TOTAL:
builder will have the burden of paving that he did not build or improve for puryou of
sated. QTY, PLUMBINGPERMIT FEE FLOOD ZONE APN
❑ Las rhe ject property,amexcnsis and Ptmn,douir,withsire:)Th,
Licenseconstruwc1searso(Sec.]DM,Business and Professions Code:)The Cemor,ofe
License Lawdoesvotoppi ma now accruement)
who
sed,potimprove,.the ConowteJ PERMIT ISSUANCE
who
ence Law,forsach pmjens with econtmemr(s)Iittnsed pursuenumhe Contnetols AITCR-DRAIN&VENT-WATER(EA) FEE SUMMARY
License lyw.
❑ I am exempt under Sec. B @ P C for this reason BACK FLOW PROTECT.DEVICE. OUTSIDEFE-ES
SANITARY Y N
• Owner Dam RECF.IPI'#
DRAINS-F100R.ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCNOOL'fAX YN
❑ Iherehy effinn lhatJ havcacenificete of conxntmxlf-insure.oreanificate of FEKTURES PER TRAP RECEIPI'p
OwnerWorkers'Compensnnon insurance or a carried copy thermf(See.3800,Lah CJ which PARK FEE Y N
covers,all employee a trader this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE r
❑ Cartifiedcopyishercbyfumished.
❑ Cenifiul copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundreddollues HOW) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
mless.)
I ceMlfyth.t in the perfarmaner.fdre work for which this man is issued,i shall WATER HEATER W/VFM/ELECIR
not employ any person is any manner ao as tat become subject to the WorkersPAID
Cm,eminionlawsof Cdifomia. Dam WATER SYSTEM/TREATING Date Receipt#
Z0 Z Applicant
2 NOTICE TO APPLICANT.Iffier making this Certificate of Exemption,y..should NEW RESIDENTIAL PLML SQ,FT. TOTAL:
LJ ; become subject the WarkersCompensation proon
visis of the Labor Calle. no most
IFF-`-- forthwith comply with such provisions or permit shall be deemed revoked. BUILDING FEE
OW. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE c5?1♦ 7V
I hereby affirm that them is a construction lending agency for the performance of TOTAL:NFEE
ELECTRIC FEE
V o the work far which lois permil is issued(Sec.30t Civ.C.)
Fr Lender's Name PLUMBING FEE
-.-J I-`adeis Address QTY. MECHANICALPERMIT
E certify that 1 have mod this application and state that the above information is
res Da Correa.i agree to comply with all city and county ordinances and State laws relating to PERMIT ISSUANCE MECHANICAL FEE V
buildi,ersnstmaion,and hemby.mbranne reprtsenmtivesofthis city to anna.poa the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII. 60{
(We)agree w save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costa and expenses which may in my way aacroeagainat anal City AIR I IANDLING UNIT(TO 10,000 CFM) ya/r� 7
in consequence of the granting of this permit.
/ AIR HANDLING UNII'(OVER IO,OW CFM)
Si rawer
er Dam EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE IfGTING UNIT(TO 10(t000 BTU) Date eceipt#
Will the applicant or future building accuser atom or handle hawdoas materia
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heath odd Safety HEATING UNIT(OVER 100.00)BTU) TOTAL:
Cada,Section25532(e)7
0Yen EI No VENTILATION PAN(SINGLE RESIDE
ISSUANCE DATE
Will heapplicamorfutum buildiagoccupant mealuipmemardeviceswhichemit BOILER-COMP(3HP OR 100,10(0 BTU)
• hmallous air compromeaa as defined by the Bay Arta AU Quality Management BOILER-COMP(OVER 100,"BTU)
UiaoinP
❑Yes ❑No NEW RESIDIN'TAL MECH. SQ.FT. NARore 29
y as 199
I have read the hmardous materials requirements under Chapter 6.95 of the AJS
California Health&Safety Code,Sections 25505,25531 and 25514. 1 understand that C�)y
if the building does not cur a dy have a terant,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of 1 s
Occupancy.
Owner m awhome l agent Dam TOTAL: ISSUED BY:
OFFICE