27224 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILUIN -ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT DIAMBING-MEDENTIFIC 27224 7 2 n A
BUILDING PROJKGf IDENTIFICATION G G '�F
BUILDING ADDRESS. �/.J� J/�� //�� SANITARY NO. APPLICATIIOONSSUUBMITTAL DATE
000:+ 6OA V,C& IChf0 i-'/n0 UNIT. I 'h LOT# ID �� 4
OW RS NAM:: PH�Or CONTRACTOR'S NAME: ^ LIC NO: NIC CONTROL
•ARCHITE GINNEEmR:Ho ,a � IC 9 S ADDRESS: n I
11
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF,
oc�) �r PERMIT ISSUANCE BLDG ELECT PLUMB MUCH V` �Io�I1 X rpt X
LICENSED CO dung IpR'SDnsof RaTIpN APPLIANCEg-RESIDENTIAL JOB DESCRIPTION
KZ n7")arcrvision amliunudanss pmvisifesionssaode.an omy theme with
00 formas 7")of DivisimnJof the Business and Professions Code,mtl my licerme is in PANELS �� tin,mu rmree and erlb<t.
6U License Class Lie,# UPT0200AMP5
rFnQy Date Common, 201.1003 AMPS
z 0o,— ARCHITECTS D17CLARATION OVER 1030 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
CZ-0 I undersand dry phots shall be used as public recmJs.
TPLicensed Professional RSIGNS ELECTRICAL
�C�u
OWNER-BU ILDER DECLARATION SPECIAL CIRCUTUMISC.
I hereby affirm that 1 can exempt from the Contractor's License Law for the
ran following reason.(Section 703 L5,Busincsx and Professions Cale:Any city or county TEMP.METER OR POLE INST.
(: HJ which requires a permit to construcl,alter,improve,demolish,or repair any stmctux
prior to its issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
d ca. 9(commeacing with Section 7010)of Division 3 close Business and Professions Cede) SWIMMING POOL ELECTRIC VALUATION p
p _y or ohm he is exempt dicefrom and the basis ronhrmlleged exemption.Any violmbnof / ��j 44�a.I
ZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
not mme than five hundred dollars(S500). NEW RESIDENTIAL ELGCIR _SQ.FT.
m ❑ I,mowneroftheprnperty,ormyemployecxwiN wagesusthcirsolecompemodmn
a3-, will dmhewcrk,Cde-Tim mreisnes'a Lienee Law
of (Se to ted
and Professions Cale:The Cmnhecfols ndwhe Law dos not apply tort owner of
property whmbuildxmimpmvsuch hape andwhodoessuch workNmffered Brough his
howemployees,provided ohm such improvemrntsarcnoo inrendetloroffercJ Borsnle.IL I GROUP RES.UNITS
ever,the building or improvement is sold within one year ofcompletion,the owner- TOTAL: ,
builder,will have the burden of proving that he did act build ar improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE �R ODZONE APN
❑construct
the Profit(Sec. 04,1, exclusively c Professionng s blicensed Cosdrotonm R7J/
License the project(Sec.704Q Business and Professions Cade)no Contractors PERMIT ISSUANCE
License Law docs uc applyroanownerofpropcny lihose itdamimprovesthenar,and
whence Low.
projects with aconvenor(s)licensed pursuanuothe Contractor's ALTER License ww. MMARY
❑ 1 um exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE. T. D E.
SANITARY Y N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOP,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IheConapsrmonImmvcce orac<ateedcopy thereof(Sec.
38or Lab C.)miof RECEIPT
FIXTURES-PER TRAP
Wmkers'Cnmpcns#fionlmorena oraccnifiW copy NermflSm.3g00.Lab CJ which PARK FEE YN
covers all employee's under this permit. GAS-FA.SYSTEM-I INC. OUTLETS RECEIPT p
Policy. BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVEft 4(EA) PLANCHECK FEE
❑ CCrdfiW copy is hereby famished.
C3Canities copy is flet wish the city inspection division. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissemion need not be completed ifthe permit is formic hundrWdmllma($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icertify that in the performance mthe work for which this permit is issued,)shall WATER HEATER W/VENT/ELECIt
not employ,any person in any manner so as to become subject to the Workers' PAID
Compensationlnwsof Califomia. Dae WATER SYSIEMTREATING Date Receipt#
Q z Applicant
Z0 NOTICE TO APPLICAN'r:If.after mukingthis Cendi'meo(Exemption,you should NEW RESIDENTIAL PCMB. SQ.ff. TOTAL:
rIn become subject to the Worker's Compensation provisions ofthe Labor Code, must
a 7 forthwith comply with such provisions or this permit shall be dermal revoked. BUILDING REE /08,6,,—
CONSTRUCTION
O 6 —CONSTRUCION LENDING AGENCY SEISMIC FEE /
1 hereby affirm that them is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: /7,0, ELECTRIC FEE 740 1 Q S
Lenders Name
OF Leader's Address QTY. MECHANICALPERMIT IEE PLUMBING FEE 170. �'
V 1 certify that I have read this application and stem that the above information is
cannot.l agree to comply with all city and county ordinances and samelaws mining PERMIT ISSUANCE MECHANICALME
70 , 04`y
UF't bailiingconstmetion,andherebyauthoriurepreerimaivesofthischyformeruponthe CONSTRUCTION TAX 6 S
Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino agairua H.
r C 140,4 _y
Imbiliaies,)m meats,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(T010,003 CFM) H. !�
in coasequ n dffic grant gohhia pemit.
e. 3/a9/5 AIR HANDLING UNIT(OVER IO,000CFM)
�C/
Signature of ApplicanVComruchir I Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,003 BTU) Dam Receipt#
Will the the Cupmmr ertino Munire cipal
ng Code. pantstore or and to Health usmmCem HEATING UNIT(OVER 100,003 BTU) TOTAL:
as defined by the Cupertino Municipal Cale,Chander!).12.and the Health and Safety
Cada Section 25532(n)t
❑Ya ❑No VENTILATION FAN(SINGLE RESID)
tlOILER-COMP(JHP OR 100.000 BTU) ISSUANCE DATE
Will tair o.icanmrd,as building becuhe ay equipmea Quality
Management a L44 a 8�
bazadom air cmnwminants as defined by the Bay Ama Air Quzlity Maragemenl
District? BOILER-COMP(OVER 100,"BTU) !d ID Yrs 11 No NEW RESIDENTIAL MECt{. SQ.FT. MAR 291999
I have=it the hmardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that VI I
if tee builJing Jmsnoa currently lmvcamnamJhm it is my responsibility mnntify the VP L'ut. I a
Occupant of the rcquiremems which must be met prim ao issuantt of a Certifcam of
Occupancy.
Owner or euthnrimd agent Date TOTAL: `70#Q ISSUEDBY:
OFFICE