27437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ELECTRICALHUILUINO PERMIT No.
APPLICATION/PERMIT PLUMBIN(:-MECIICA
BUILDING DIVISION NUILDIN'O PRIIJRLT'IDENTIFICATION 27437
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBM[TTALDATE
L/T UNIT# LOTMI�q 2 -a 3+� 3
0 NERS NAME: PHONE,: CONTRACTORS NAME LIC NO'. ✓
'tom p n" m SIC CONTROL#
R ITEC /ENGINEER: LIC NO: ADDRESS. T 0� El
ONTAW PHONE:
� QTY. ELECTRIC PERMIT AEE BUILDING PERMIT INFO
2 le, O I? mJRI.e / //_/_ J> LD ELECT PLUMB MECH
[P 660 PERMIT ISSUANCE El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm thal l am licensed under fCha t 9 th TOB DESCRIPTION q
OCZ Y Provisions Chapter ChImNtV reoMaI-
'WOO w Section a and of Division 3 of the Business and Professions Cada and my license is in PANELS
<W F full force and effect.
FZW License Class Lic.a UPT0200AMPS kc),ldei' G,/✓Q
N<c. Date Contractor 201-1000 AMPS
,>ONZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z�O I understand my plans shall ba used as public records.
SIGNS ELECTRICAL
Licensed Professional
a�W< IOWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
j40�U I hereby affirm Nal 1 am exempt from the Convenor's License Lnw flat Ne
Hct following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F O Q which requires a Permit to construct,alter,improve,demolish,or repair any stmnure
ce�Y2 nr its issuance.also the applicant for such Permit file a signedstatement POWER DEVICES
prior quires pp poserLa
e,'aO 9(comman he isncing withsuanno")of the iivisinf the me Burins and Ptah ions Coe)hapter SWIMMING POOL ELECTRIC VALUATION
ayo y(commencing with Section 7")of Division3of the Business and Professions Code)
^:� lather he is exempt therefrom and the basis fmnhc alleged exemption.Anyviolntiosof OUTLETS-SWITCHES-FIXTURES
1—Za Section N3 l S by any applicant for a permit subjects the applicant to a civil penalty of / 3 J V
5 E G not more than five hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ.FT.
Wt: ❑ 1.a.sownerofiheproperty.ormyemployeeswithwagesastheirsolecompensation, STORIES TYPECONSTRUCTION
c, will do the work,and the swcwrcisnol intended proffered for safe(Sm.0044,Business
and Professions Cade:The Commences License Law does not apply to an owner of
property whobuildsorimpmves Nercon,and whodiessuch work himselfor through his OCC.GROUP RES.UNITS
woompinyecs,providal lhot such lmpmvementsnrenolimenJW ormffered Porsel,.IL
however.the buildingor impmvemenl is sold within m¢yeaofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑ I,azownerofthc pmpeny,amexdusively conlrecting witnlic<nsed conuamors to QTY. PLUMBING PERMIT FEE FLOOD zoNli APN
construct the project(Sec.7044,Business and Professions Code:)The Contracmrs
License Lawdoes not apply in anowneroTimpeny who builds or improvesthereon,and PERMITISSUANCE
whoembaces for such projects with aconlractims)licensed pursuant lathe Contractor's se Law.
License
ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ l um exempt under Sec. B&P C for this reason BACK FLOW PROTECT.pF,VIC OUTSIDE FEES
SANITARY Y N
L Owner Date RECEIPT It
DRAINS-FLUIDR .AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TA% YN
I Ocrcby affirm that I have a certificate of consent m self-imvre,or n certificate of RECEIPT p
PIX' -PER TRAP
rkerY Compenvtion lnmmnce ora cenifiedcopy thercmf(Stt.3800.Lab C.)wbich PARK FEF. Y N
rs allemploy en it./1 GA -EA.SYSTE -I INC.40 S RECISION
tblicy#� 7 BUILDING DIVISION RES
Company ��1(^��F(Tlyld v GA -Is.A.SYS1HM-OVER4(EA) LANCHECK IEE
^ '
Certified isnerrnymmrsned.
❑ Certified copy is filed with the city inspection division. Gft SE/INDATIU_WpIllshWiRCEPTOR G ADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR4SETRiIiPjky - SOIL.SRE
COMPENSATION INSURANCE
('Ihis,monn need not be completed ifthe permit is forms,hundred dm11urs($100) SE :R-S A Y- TO EA.]UO ENERGY ITE
orless.)
I certify than in the performance mfthe work for which this permit is issued,l shall W+_HEATER ANp,
not employ any person in any manum
sec as to become subject to the Workers' PAID
z Comprmafion Lawsof California. Dam WA eR SYSTENETREATING Dote Receipt#
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NE RESIDENTIAL PLMB. SQ.FT. TOTAL:
p] become subj,a to the Worker's Compensation provisioner of the Labra Code,you..at
forthwith cola with such this t shell be deemed revoked. BUILDING FEE
comply provisions or Permit
0. Q CONSTRUCTION LENDING AGENCY SEISMIC RE
Z) z I hereby affirm that there is it construction lending agency for Ne performance of TOTAL ELECTRIC ITE
U p the work for which this permit is issued(Sec.30IR,civ.C.)
I�-++ Lender's Name
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING Pee
U I cenify that I have read this application and state that the above information is MECHANICAL FEE'
P.
Cat l agree to comply with all city and county ordinances and state laws mining to PERMIT ISSUANCE
F_ ,) buildingecnstructimn,and hereby amhodae rcpresenlativcs of this city memeruponthc
above-nemtioued f CONSTRUCI'ION'I'A%
V z property far inspection purposes. ALTER OR ADD TO ML'CII.
(We)agree Ila save,indemnify and keep M1ay in a the Cityofa against
s against
liablliriee,jud• and expo swM1ich may in any way accrue against said City AIR HANDLING UNIT IT ILL00f1 CPM)
commyu gof permit.
AIR HANDLING UNIT(OVER 10,1100 CFM)
Sign n pp a naemr Dab E%HAUS'1'HOOD(WIDUCT) PAID
I TAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
WiII the opplicam or future building occupant store or handle hamrboo material
as dcfinW by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNI'i'(OVEN IW,IXq if1'U1 TOTAI-:
Code,Sri 11253J2(a)'I VENTILATION FAN(SINGLE RFSID)
❑Vc. ❑No
ISSUANCE DATE
WilltheappliC torfutumbuilding«cup tum cuipmenl.ordeviceswhichemit BOILER-COMP DIIP ON 10ILM)BTU)
norardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
isWcn A � /ss
❑Ycs ❑No NEW RGSIDENI'IAI.MI:CII. SQ.FT. 6J
I have read IM1e M1araMoae materials rcquiremems under Chapter 6.95 of the MAR
a� a�
California Health&Safety Code,Sections 25505,2553]and 25534. 1 understand that MAR 22199��
if the building does not currently have a tenant,that it is my re5pnnsibilt,b notify the
occupant of the requirements which must be met prior to issuance of a Cenlfieare or
Occupancy. IFY utt 1.1 {•".
Owner or mol mi,od agent Date TOTAL: ISSUED BY:
OFFICE