27366 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUIILIH .-ELECTRICALPERMITNO.
APPLICATION/PERMIT PING R OJEC17ECHANICAL 27366
R1111.U1NC DIVISION BUILDING PR(3.IECf NM.N'fll+IhATION
BUILDINGADDRESS: SANI'T'ARY NO. AP PLICA TON SUBMIT)Al.DATE
L a N AJ UND'N LOT �_
OWNERSNAME: PIJONIIl CONTRACTOR'S NAME: LIC NO: NIC ONT'ROLN
SOSI.L 2 'IPJ am
ARCfII'IRLT/ENGINffiR: LIC NO: ADORI'SS:l /`mak A✓L 11ONTAC'P: PHONE: o BUILDING PERMIT'INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MF.CII
PERMIT ISSUANCE
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB IIP CRI N
pyry Ihcrchy off mnhm lamlicensed underpravisinns ofChaplar9(commencing with _ / n W�C
tu�-00 Section]OBB)of DivisinnJof N<Bminas end l'mfeasiom Code,and mylicrnse is in PANELS /l
- full force onJ effa y 1 /�
aL License s r 9 I.ic.N U J UPT02MAMN L10Yjfj. /e*e
y<y cmc Contractor O-le 201-IIXI(IAMPS
,zO y^ ARCIII'1'ECT'S DECLARATION / OVER I"AMPS SQ.FT.FLOfJft ARM $/SQ.FT.
OZ—e 1 understand my plans shall be used as public records.
y F s�i SIGNS ELECTRICAL
q Licensed Professional
5 yy� OWNER-Dempt Io a the Contractor's
SPECIAL CIRCUIT/MISE.
"Oy I hereby n.So dm 1 am exempt from the Contmmor's License Law for the
following ream,paecti to co3L5,Busher.si prve.cha ionaCNr:Ano city wrichuy TEMP.MET ER OR POLE INST.
W which inquires issuance,permit to sambas.eller.improve,demolish,fi rcpzip ed ewaurc
W } dedbeslnsedursuant to the he provisions
fore ch he Conamoil's License
ase Law(Chapter
POWER DEVICES
� �p 9(con is licensedpursuantof svision ofCm Business
Liceme Laions Co ter
a o�' 9(vommencing with Section 7000)of Division3of the Dusincss and Professions Code) SWIMMING POOL ELECTRIC //////VAL/UATION
p--y
or 7031. by mpt
rdromand the baspermit
rb alleged exlicantn. civiny l
of OUTLETS-SWITCHES-FIXTURES /!/ /SO
Fla, Section than iv anydreddontIntapermit subjecuthe applicantmecivil pcsWty of J (0
0not more than five hundred dollars($500). NEW RESIDENTIAL ELECIR
Oo ❑ I,stows,nsfthcproperty,armyemploymswimwagcsesthcirsolecompensation, STORIES TYPE CONSTRUCTION
9 will do rinnwork,and the stmctum is not imendedoroffeyed forsale(Sec.]044,Business /
and Professions Cale:The Contractor's License Law does not apply to as owner of
pmpeny whobuildsor improves thereon,andwhodou suchwork hineselforthrough his
own employees,postural such improvcmentswe notintendeduroffered forsee.If. /OCC GROUT' RES.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner. TOTAL: J F�
builder will have the Maden of proving that he did not build or improve for purpose of
sale.).
❑ Lmowner o(the Progeny,eco ex<lueivelycomnaing wimli<ensed contra a onQTr PLUMBING PERMIT FEE #.000 ZONR ANN
consthe project(gee.]044,Business and Professions Code:)The Contras 's PERMIT ISSUANCE
License Law does not apply manownerofpropmy wbobuilds or improves therco and
whocanbacts formed projects with u conumums)licensed pursuant to the Contr cmr's ALTER-DRAIN@VENT-WATER U)
License Law. FEN.SUMMARY
El we exempt under Sec. .B @ P C for this BACK FLOW PROTECT. 1
SANIT BY Y N
OwnerDate DRAINS-FLOOR,ROO ON A RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOI.TAX Y N
❑ Ihcrchy affirm that l have a certificate ofcomcntto self-insure,or a certificat f FIXfUR -PER RECEIPT
Workers Compensmionlnsumnceoracenifiedcopythemof(Sm.38W,UbC)wh1 PARK IE Y N
cute.ell emP! �s� def thispcsmity GAS-, V ' -I C.4 RECEIPT'N
Policy# ,,cayy e9 -acN" - - - BUIL DING DIVISION FEES
rn
ay_ GAS-EA.SY LM- E PLANCHECK FEE
El C
❑ Entfiedicopy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASWIND 4STIL AS INTERCEPTOR ' GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('This section need not be completed ifthe permit is forme hundred dollars(JIM) SEWER-SANITARY-STORM EA.20011T. HNERGYIEH
or less)
I certify that in the perfarmance of the work for which this permit is issued,I shalATER HFATER W/VEbT/ELECTR
not employ any person in any manner so ss to become subject m the Worker% PAID
Compensation Luwsof Culifomin. Date TERSYSTHM/IREATING Dom ftmciptq
O Z Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Cendmate of Esemption,you should NEW RESIDENTIAL PLMIL SQ,PT.
rVf become subject o the Workers Compensation provisions of the Lather Code,you must
a forthwith comply with such provisions orchis permit shell be dcamed revoked. BUILDING FEE tea
W Q, - CONSTRUCTION LENDING AGENCY SEISMIC FEE O
z Ihereby affirm that there is a construction lending agrnsy for e performance of
O the work for which this permit is iuued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
O
1-maim',Name
4aPLUMBING PEE
der's Address QTY. MECHANICAL PERMIT FEE
1 certify that I have read his application and nn¢that the above information is MECHANICAL FEE
correct. I agree to comply with all city and county ordinances arM amre laws offering to PERMIT ISSUANCE
rQjj building construction,and hereby authorize repmunativesofthiscio,lumber upm the
above-mentioned propcny for instmedon puros
pes ALTER OR ADD TO MECH. CONSTRUCTION TAX
L) �
(Wm agree m.wve.indemnify and keep harmless the City of Cupertino against
Iiabiliries,judgmenrs,costs and expenses which may many wayuccrue against said City AIR HANDLING UNIT(TO I0p00 CFM)
in consWucnce of the ornti of is Permit. AIR DANDLING UNIT(OVER 10,000 CFM)
1-1 y-z-
SignnuucofAWlicatn/Cnmmemr Dago EXHAUST HOOD(W/DUCD PAID
I IAZARDOUS MATERIALS DISCLOSURE [MATING UNIT(TO 100,000 BTU) Data Rtteipt p
Will the applicant orfumm building occuporm mwe m hmmle harmonious material HEATING UNIT(OVER 100.000 BTll) T
as defined by the Cupertino Municipal Code,Climber 9.12.and the Health and Safety
Code,Seenon 23532(x)7 V17NTILATION FAN SINGLE RESID)
❑Yes ❑No
BOILER-COMP(JHP OR 100,(100 BTID ISSUANCED TE
Will the applicant orfuwre buildingmcupam umtyuipmrnwrdevices whichcmit � A �
�ho=xair con dominium defined by the Bay Atm A D
Air Qualify Management BOILER-COMP(OVER 100,000 BTU)
Disbicte as 7
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. APR ._7 1995
1 have mad the hamadous materials rrmanmenu under Chapter 6.95 of the �(
if the
building
Health @Safety Call,Sections25505,2533]add 255U.1understand that CI
{V
mcupuiloft tlmsnrnucals whichly must
the
hmet it myssuanc responsibility tanficat rhe V f Uh UIJNCNrINO
Occup an of the reyuiremems which must be met prior m issuance of a Certificate of
Occupancy.
Owner or awhoriuJ ngem Data TOTAL: ISSUED BY:
OFFICE