27842 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILD
ILD( r-LLhCTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27842�e /I4 G A
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION o
BUILDING ADDRESS: /� {/.� D art �//� SANITARY NO. APPLICA'DONSUBMITLILDATE
I ,CL Po/ G g iti o UNIT# / /CLi 1 e:1.J{ LOTp F _
O S AME' r PHONE CONTRACTOR LIC NO: 7—S
JQn Om of �O U r N/C COMI'ROLp
\RCUITECf/ENGINEER: Gd LI O: - ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE `
PERMIT ISSUANCE BLDG EL)CT PL MECII
LICENSE. CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL rK47`/ JOB DESCRIPTION lh6y
WPCZ I hereby afpmvhat l am licensed underprovisions ofChapter9 tcOmmencing with
F 00 1-11 Ca a and of Division 3 of the Business and Profesilons Cade,and my license is in PANELS {� I
q�j [EE['' full force and effect, r
fZW License Class Lie.is UPT02MAMPS
te, Data Comacmr 201-100D AMPS
ZOy2, ARCIIITECTS DECLARATION OVER LBBB AMPS SQ.FT.FLOOR AREA $/SQ.Ff,
O Z— I undersand my plans shell ba used m public retards.
<',=J SIGNS ELECTRICAL
<yf` Licensed Professional 0(
L.mce< OWNER-BUILDER DECLARATION SPECIAL CIRCUI'I'/MISC.
pX'OdU I hereby m.(Se than 1 nm exempt from sive Profession,
Co e:Anse taw for the / Y
1:1 Eb"ir followwhichingreumaermiit Oo31.5, t.altess ad,imprve.de oli Co de:An,cityorcountyTEMP.METER ORPoLCINST.
f3m poortdoquircnngamut re conxwe6aper,improve,demolish.or repair anyysmnment
ChCan}� thione itsissuancepalsorequith the applicant of thesuch Copemtitto Lfile a ikentgned sammcm POWER DEVICES
W C<O p that Idc is licensed pursuant m the provixionx of the Commdors License Lew(Chapter
44�d0 ' 9(commencing with Section ltg)(pof Division 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_an
it that 131.5 by exempt therefrom the bmia for the Alege,plication.Anyvironeionof OUTLETS-SWITCHES-FIXTURES
nor mo)031.5 by any applicant fora permiuubjcea Ne epplicanu...ivil penalty of 7 Fj
not mnr<than five hundred doll urs($5007. NEW RPSIDIiNT1AL[LP.CTR .
m ❑ 1.mowneroftheproNnY,ormyemploy swiNwagesnsthcirsolecompenMtL.or, SQ Pl'. S'TORIIS TYPE CONSTRUCTION
q _ will dathe work,and lhestrucwre isnot intendcdoroffercd forsale(Sec.7044,Business
and Professions Code:The Contractors license law does not apply do an owner of
progenywhohuildsorimproves'lemon,a whodmssuchworkhimsclfonhroughhis
own employees,provided thatsuchimpmvements are unintended oroffered for sale.If, q C.GROUP RES.UNITS
however,the building orimprovemem is sold within oneyecrofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
We.).
❑ 1,asownerefthepropeny,omexclusivelycomractingwhhlicensticontactonto QTY. PLUMBING PERMIT FEE OZONE APN
construct the project(Sun.7044,Bulinus and profcssims Codeynic Contractors PERMIT ISSUANCE
License Law does not apply to m ow ac r of property who builds or improves thereon,and IV
whocontruca forsuchpmjmts with accountants)licensed pursuant to the Contractors ALTER (EA)
License Law. F. UMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OU 1 SIDE E
SANITARY Y N
Owner Data RF.CF.IPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherehy nfOrm than lhnveecenificate afconawuo sdF-insure,orettnificem ter RECEIPTM
Wonsan'Cam Fl%TURES-PPR I'I1AP
penaedon Insurance copy tM1ereof(Sec.3800,fab CJ which PARK ME Y N
coversall employee's antler Nis permit. GAS-EA.SYSTEM-1 INC 4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE O _`
❑ Certified copy is hereby famished.
❑ Certified copy is riled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION I-MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifdhe permit is for one hundred!dollars($100) SEWER-SANITARY-STORM E,.2001T. ENERGY FEE
or less.)
I cenifydm in the performance of the weak for whichthis permit is issuW.I shall WATER HEATER WryFNT/ELECI'R
not employ any person in any mature
s o as to become subject to the Workers' PAID
Compensation Iowa of California. Data WATER SYSTEM/IRPATING DateRe #
O z Applicant
z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL:
t•+ V] become subject to the Workers Compensation provisions of the labor Cade,you must ry
5 forthwith comply with such provisions or this permit shall be deemed revoked BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE �O
z I hereby affirm dust there is a construction lending agency for the performance of
U C) the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: /7o ELECTRIC FEE 1 70 0
(r Lenders Name PLUMBING FEE
U Lene I c Address the, QTY. M1IECIIANICAL PERMIT FEE
I certify d so I comply
fwd this application and store rhes the about information is
canet.lagree to complywith
nebyall
suisyaM county
eprovnNinanmsand sante lawsexistingvongto PERMIT ISSUANCE MIiCHANICAI.FEE
U Z alwavengentionudinmunJ herebyantionprcoses, ntivos of thio city torntcr upon the CON$TRUCTIONTAX VO�
U ,Z ebov(We)agree progeny for inspection purposes. ALTER OR ADD TO MEC'H.
(We)agree to save,indemnify and keep harmless theof Cupertino t s against
liabilities,judgmnts
e ,rosin and expenses whichmy in any wayy eccruengvnn said City AIR I{pNDLING UNI'((TO 10'"10'" FM
C ) a aF O!22-140
m ennsequen f the granting of this permit.
`� /'J�` AIR DANDLING UNIT(OVER 10,000 CFM)
SigWi reof ApplicanV(Co'mmn I/ UT puma�J EXHAUST I IOOD(W/DUCI) PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hnaerdous material
as defined by the Calamine,Municipal Code,Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100,(100 BTU) �/TTOOTTAL:
Cade.Section 25532(e)Y
❑255 ❑No ENTI )kl(/
VENTILATION FAN(SINGLE RESID) '
CNBIDATE
Will thenpplicamorfmure buildingmcupantuseequipmw
cnrdevices whichemROLLER-COMP UHP OR 100.00(1 BTU) ISJ'BAMM
it CC 6L/J
hiaurdous an contaminants as definW by the Buy Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District, APR 271995
13 Yea 11 No NEW RESIDENTIAL MECH.—SQ.IT.
I have read the Intentions materials requirements under Chapter 6,95 of the b�'�
California Health&Safety Code.Sections 25505,25533 and 25534.I undersand that �# 1 Vf I/VY
if the building does nor currently have a mount,that it is my responsibility to nmify the --
occupant of dive iremmrts which must he mut prix to a tt f a Certificate of
owapaney. �y�I �.
ice_ �Ff,
Owner or dhoriuA agent Dnm TOTAL: /7De ISSUED BY:
OFFICE