27117 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIY,DIFC-ELRCTRTCAT PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING R OUEL7RCIlANIFIC 27117
RIl11.DIN1:rNOJECT IDHNTIPIUA'I'ION
BUILDING ADDRESS: SAND'ARYNO. APPLI TIONSUBMITTALDKIE
�"- UNIT# LOT If {//J�' IO .t A , PHONE- CONT 'OR'S NAMIL LIC NO:
6 O J N/C CONTROL#
•ARC]11'E /FNGIN LIC NO: ADDR S ❑
CONTACT: PHONE: BUILDING PERMIT'INFO
QTY. ELECTRIC PE FEE
BLDG ELECT PLU B MIiCH
PQiMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Clre 2 I hereby affimUhat l mn licensd undespmvisionsofampmr9(commrncin$with
POO Section 7")af Division 3 ofthe Business and Professioodand
e, mylicrnm is in PANELS
full force and etfec ns C
FUV yJ Date e- C/r_.�Cour GO lIP T02W AMPS r
may Dula Comrucmr 6 201-IOW AMPS
ZHD ARCHITTA'I'S DECLA TION / OVER IOOO AMPS SQ.YG FLOOR AREA $/SQ.PI'.
O Z 4 @I understand my plans shall be used as public records.
P-k: SIGNS ELECTRICAL
<Y Licensed Professional
y�o4a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0OiF I hereby affirm door I am exempt from she Contmeme.Lt...law for Ne
:O m¢ following mason.(Section 7031.5,Business end Professional Code:My city or county TEMP.MEIHR OR POLE MST.
m J which requires a permit to construct,alter,improve,demolish,or repair any structure
primmitsiamenes also requires the applicant(orsuch permit to file a signed assessment PO\VER DEVICES
y�j O that he is licensed pumvma to the providans of the Contractors License law(Chapter
d4o�' 9(commencing with Section 7")of Division 3 oflbe Business and PmRssiom Code) SWIMMING POOLELECIRIC VALUATION i
ly�y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-PIXTGRPS
Section 7031.5 by any applicant for a permapplicant it subjects the applicano a civil penalty of
G not more than five hundred dollars(S500L NEW RESfDP.N'1'IAL ELECIR _SQ.FT.
w ❑ I,nsownerofthepro any,ormyemploymswithwagesastheirsolecompe..tion. STORIES PHCONSTRUCI'ION
a will do the work,andthe structure isnot indendedoroffered fm sale(Sm.7044,Business
.it Professions Code:The Conuacmr's License Law does nm apply to m owner of
property w ho m ilds or improves themor.and w ho dos such work himsel f or through N s
wnemployms,providedmm such improvemcrosme nmintenddoroffered portable.If. OCC.GROUP RFS.UNITS
however,the building or improvement is mid within oneyearofwmpinion,the owner- TOTAL 1
builder will have the burden of proving door he did not build or improve for purpose of
sale.).
❑ Las owner ofthe property.me.clusivelycontreding wilhlicrnseJ conlracmrs to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
amsuuer the projmt(Sec.7044,Business and Professions Code:)The Con tamer's
License Luw(lcesnotapplyto nownernfpropeny whobuildsofimprovesthereon,md PERMIT ISSUANCE -7/r v-
whoaomroets forsuch projects with acmnmbtor(s)licensed pursuant to the Contractors ALTER-DRAIN&VENT-WATER(EA)
Licenm Law. SUMMARY
❑ I um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE ANITARYTSf3 A N
Owner Date ITT#
DRAINS-FLOOR.ROOF,AREA,CONU.
WORKMAN COMPENSATIONDECLARA.... CH001.TAX Y N
• ❑ Ildemhy affirm thmlhave ecenificme ofconsrnuoselGinsure.ore certificate of RECF.IPI'p
FIXTURES-PER TRAP
Workers'Compensation Insurance or acenified copy therm((Sm.36W,lab CJ which �� ARK FGE NIt
covers all employees order this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS � PT#
Policy# BUI GDIVISION PCIS
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCI IECK FEM-41
❑ Cenifded copy is hereby fumishad,
Lnllied IloW is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FIR
T CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This sorban need not he completed ifthe permit is fm one hundrddollan($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY Flip
or less.)
I certify that dm perfommnceofthe work for which IRs pemtit is isolated.I shall WATER BEATER W/VEMDELECTR
.or employ any person in any member m as to became subject to Ne Workers PAID
Cnmpcnsmion Lawsof Califomia. Dam WATER SYSI'F.MRRPATING Uotc Receipt#
O z Applicant
NOTICE TO APPLICANT,IL after makingthis Cmificate of Exert TOTAL:
pion,you should NEW RESIDENTIAL PLMN. SQ.PI'.
tzr
forthwith
jmtmdhe Worker's Compenmtion pmvisinns oflhe L.00r Cwtood. must
fnrtbwith comply with such provisions nr this permit shall he deemd revnkd. BUILDING FFai
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a momuction lending agency for the performance of
L) O the work for which this permit is issued(Sec.3(197,Civ.C.) ELECTRIC FRE
Lender's Name o PLUMBING FEEO F Lender's Address QTY. MECHANICAL PERMIT' FEE
V I certify that I have read Nis application and store door the above information is
correct.I agree to comply with all city and county ordinances and sore laws relming to PERMIT ISSUANCE MECHANICAL ITE
building construction,and hereby amhndze mpreaenmtives of thiaciry m enter upon the
L) ohnve-memiond property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
We)agree to save,indemnify rod kap hormless the City of Cupertino against
lhumili ostsandexpe, which may many way accrue eeei.tmid City AIR HANDLING UNIT(TO 10.0W CPM)
bed rn cow o t mnl�i yyGt m mot.
D AIR HANDLING UNIT(OVER IO,IX)n CPM)
ig sew f pplicam/C
dimuffor Data EXHAUSTHOOD(wAMm
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO IW,0011BTU) Dam Receipt#
Will the applicant or Norm building mcup.,...or handle harsrJom material HEATING UNIT(OVER 100,000 BTU)
as defined by the Capenino Municipal Cue,Chapter 9.12,and Ne Ilcalth and Safety
Cock,Seri 25532(e)?
0Yes El No VENTILATION PAN(SINGLE RESID)
Will theapplicnnmrfuturcbuilJingmcupnm useegoipmenmrJevlceawmar it BOILER-COMP(3HP OR 100.000 BTU) ISSUANC9 DATE[
hnuudam air comaminams as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,00BI TU) C
Disuictl
❑Yes ❑No NEW RESIDENTIAL.MF,CH. SQ.IT. OCT e 5 199
I have read the harardmu materials requirements under Chapter 6.95 of the
Califnmia I leahh&Safety Cue,Smtions 25505.25533 end 25534. I underm nd Nat
if the buildin doesnm
current huv mnen4 Net it is my responsibility to notify the C11Y Ur wrtnr-
oecupumord be met prim m issuance of a Certificate of
Occupn �u �
O�imr edTihnnzed agent
Dm5 9'OTAL: ISSUED BY;
U