27835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUTN
HUMU-ELECTRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 27835
BUILDING PROTECT IDEND FICA'DON
ws— logF2— Z' LV ^I P/ SANITARY NO, APPLICATION SUBMITTAL DATE
J NI'1'q LO f4
OWNERS NAME' PH E: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
xa-Ock j Le K K 2
„•ARCHITECI'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMI71NFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
Lr thatI on
CONTRACfOR'SDECLARATION APPLIANCES RESIDENTIAL —` )plL r>S,gCRIpTI
OCZ Thereby affim CENSE under DECLARATION
mChapt(commencing with
m00 Section 7001 of Division 3 ofdie Business and Professions Code.and my license is in PANELS
yF- full force a ad effect.
QI,,,ZW license Clans- Lia# UPT0200AMPS
y?y Date - Contractor 201-1000 AMPS 5 FFT
T.FLOOR AREA $/SQ. .
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS Q
OZ—a I understand an,plans shall be used as public records.
F y F; SIGNS ELECTRICAL
QYf,, Licensed Professional
�ycQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaU 1 hereby affirm that I am exempt from the Contractor's License Law for the
W a m following reason.(Section 9031.5,Business and Professions Code:Any city orooun.y TEMP.METER OR POLE INET.
F- �; which requires a permit to commas,airing improve,demolish,m repair any structure
�wY2 prior to its issuance,also requires the applicant for such permitm file tidgnedstatemed POWER DEVICES
,W<C) that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
nEaW 9(commencing with Scotian 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W^y or that he iseacmpItherefrom and the basis for the alleged exemption.Any violation of Ol7REfS-SWITCHES-FIXTURES
F Z 4 Section 7031.5 by any applicant for n permit subjects the applicant W.civil .It,.f
�y0 nut more than five hundred dollars($500). NEW RESIDENTIAL ELELTR _SQ.FT.
CFo ❑ 1,vowncroftheproperty,ormyemployecswithwagesastheirselecompcnsutim, STORIES 'IYPECONSTRUCTION
as ° will&the work,and the structure is not intnMedoro(feed foraale(See.9044,Business
and Professions Code:The Contractor's License law docs not apply to an owner of
property who huildsor improvesthereon,and whodoes such work himselforthroughhis
employees,prnvidalthat suchimprovementsarenotintendedoroffered forsale.If, OCC.GROUP RES.UNIT I
howcveq the building or improvement is sold withinone yearofcompletion,theowner- TOTAL:
builder will have the burden of loving that he did not build or improve for Purpose of
❑ Las uw'nerofthe property,dnenclasivelycnntrading withlicensed contmnoram QTY. PLUMBING PERMIT FEE FLOOD'ZONL pPN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does not apply m an ownerofecopcny whobuildsorimproves thereon,and
who contracts f n,mb projects with ammrunorhd licensed pursuanuo the Conounnr's
Liccase law. ALTER-DRAIN&VENTWATER(PA) PEE SUMMARY
❑ 1 am exempt unJcr Sec. ,B&P C for Nis reason BACK FLOW PROTECT,DEVICE OUTSIDE ItiFS
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECF.IPTp
WORKMAN COMPENSATION DECLARATION SCHOOLIAX Y N
❑ Thereby aff that l have a cenificale ofeonsem to self-insure,or a certificate of FIXTURES-PERTRAP RECEIPT#
Workers Compensation lasuranceoracceificicopy Nconf(Sec.3800.IabCJ which PARK FEE Y N
cover,all employee's under this permit. GAS-EA.SYSI'FM-1 INC.4 OUTLETS RECEIPT#
Policy IT BUILDING DIVISION FEES
❑m Ccniried co hereby famished. GAS-G.SYSTEM-OVER 4(EA) PIANCHF.CK FEE
py is
❑ Cenilied copy is riled wan the city pe 'joiC GREASEpNDUSTRL WASTE INTERCEPTOR GRADING PEE
��s (n�
CERTIFI MPTION FROFFWD KE S'i 1� GREASETRAP SOILS FEE
COM SATI NCif/
(Thiosectioo need nntbce plated l[th uis for ane hundred dollars(5100) SF.Wf?R-SANT'PARV-STORM EA.201 I?NP,RGYIEB
or less.)
I certify Nat in the performance ofthe work for which this permit is issued.)shall WATER HEATER W/VI:NT/ELECTR
not employ any person in any manner so as he become subject to the Workers PAID
Z Compenantion Law.sof Califomla. Date WATER SYSTFIATTREATING Data Receipt#
Applicant
ZO NOTICE TO APPLICANT:If,after making this Certificate of Enemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
.�. become subject the Worker's Compensation provisions ofthe Labor Cede,you must
a > forthwith comply wit such provisions or this permit shall be deemed revoked. BUILDING FEE
600. Q CONSTRUCTION LENDING AGENCY SEISMIC ME
1 hereby affirm that is a construction lending agency for Ne performance of
V 'Z the work nor which this permit is issued(See,3197,Civ.C.) TOTAL: ELECTRIC FEE
O Lenders Name PLUMBING FEE
F Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and state that the above information is MECHANICAL ME
W c met. I agree m comply with all city and county ordinances and state laws relutiagt0 PERMIT ISSUANCE
ybuilding contacted,and hereby audience representatives of this city to enter upon the CONSTRUCTION TAX
U 2 above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to gave,indemnify and keep harmless the City of Cupertino against
IiabiliticcjudgmenR covu and expenses which mayimany way acrnsotirm said City AIR HANDLING UNIT(10 10,000 CFM)
consequence otanting (Nis permit.
3 _2 _qT AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Cmnlmdnr LDLata EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS QATERIALS DISCLOSURE
HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will these Calamineant or future buiedi Code,
Chapterrn
2,and to Hardousmalfety HEATING UNIT(OVER 100.000 BTU) T 1'
as define)by the Cups�rtino Municipal Cedq Chapter YJ2,and the Health and Safety
Code,Section 25532(a)? VENTILATION PAN(SINGLE ftFS1U) 95
❑Yea ❑No
ISSUANCE DATE
Will the applicant orfuture mildinguecupum useequipmerandevleea win. omit BOILHR-COMP(3HPOR IN,M)BTU)
haeardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) A• A Distract? ElYes 114 '
YNo NEW RESIDENTIAL MECH. SQ.FT. //s.A
I have read the honorees nationals requirements under Chapter 6.95 of the AR p
California Health&Safety Cede.Sections 25505,25533 and 25534. 1 understand Nat /l
st
fthc building does not mmently have atcnun6thm it is myrestimmiility,m notify he Apr J'
wcupant of the requircmemc which anon be met prior In issuance of a Certified¢of
Owner or xwhorieeA agent Dore TOTAL: ISSUED BY:
OFFICE