27777 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO . . PERMIT Na.
APPLICATION/PERMIT PING PROJECT ENTEFIC
CAL
BUILDING DIVISI BUILDING PROJECT IUEN'1'IFICA'1']ON 27777
BUILDING ADDRE. SANITARY NO. AMUCATIONSU.BBmtrTALDATE
T 2 LOTp
OWNERS NAME: HONE: CONTRACI'OR'SNAME: LIC NO: J
I N/C CONTROL#
\RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
HEW fsLECI' PLUME MIiCH
PERMIT ISSUANCE /D�—ate- ❑
LICENSED CONTRACTT OR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ I hcrebyieffirm that lam licensed under Provisions of Chapter 9(commencing with JOB DESCRIPTION
0100 Section]000)of Division 3 of the Business and Professions Cade,and my license is in PANELS
yZW License
Clasfit I force Oil-Tram. UP TO 2W AMPS
Q Z W� License Cosa Li<.p
pFi<� Dula IECTS I 201-1000 AMPS
Fy2, ARCHITECTS DECLARATION OVER 11X0 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
0'O m I mlderslund m hall be used as public mmordv -1,1'�r �/►�( 2C
O G'-p Ypunxa pts 8�o
SIGNS ELECTRICAL \\\
Qycaj LicenuJ Professional
d'0ca<WU OWNER-BUILDER frmDECLARATION SPECIAL CIRCUR/MISC.
KOaU 1 hereby affirmn.(Se tthation I am exempt Tran the Contractor's License Law for @<
0+131+-rn following reason.(Section 7031.5,Business and Peofessions Code:Any city or county TEMP.METER OR POLE INST.
F LL 0 Q which requires a Permit m Conswet,alter,improve,demolish,or repair any structure
,W}� primm its issuance,.1mnd, ocsthC app licantfarsto1i,rmi0o fileasignMstammem POWER DEVICES
,=<0 Ihm he is licensed pucsuam m the provisions mile Comracmrs License Law(Chapter
e XaM 9(commencing with Section Division 3 ofthe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
lD_a or that Sectiohcisex mpt by any
applicant for
the basisforpeed the apt
Any violation of IJTLEIS-SWITCHES-FIXTURES 2h ���
Seaton]tha5veanydred dollforapermit svbj«¢the epPlicam toacivil penaltyof
i move than rofhupmr ny,ormSSW). - NEWRE4IDENTIALELECTR SQ.FT.
5F� ^❑ 1,aspwncrofthepropcny,ormyemployaswithwegcsastheirsolecompcnsefion, STORIES TYPE CONSI'RUCI'ION
ai20 will clothe work,and the stm<tum is not imendedoroffered forsale(Sec.7o4l,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
progeny who builds or improves thereon,and who does such work himwlf of fimm,h his
cmployecs,provided that such improvements sound mandedrnofferedforsale.U, OCC.GROUP RES.UNITS
however.the building orimprovemcnt is sold wilMn^me yearofcompletion,the owner- .1.
builder will have the burden of proving that he did not hold or improve for purpose of
-Ie.).
❑ I,asownerofthepropeny,amexclusiselywmr tingwiJlicenud nvectomw QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Construct the project(Sec.0044.Business and Professions Code:)The Compatriots
License Lawdoes mol apply to an owneTofpropeny who hm1dsor improves lherwm,rand PERMIT IS DAN /p
wh pmmxma for such pro3ects with acomrcctogs)licensed I, uantwtbe Comracmrs AL HER- RAIN&VEN AT
WER LA
License law. (' ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK OW PROTECT.DEv1 OUTSIDE FEE.
SANITARY Y N
O.Cr Date RECEIPT N
DRAI -FLOOR.ROOF.ARF.A,CO�
WORKMAN COMPENSATIONDECLARATIONItAT10N SCHOOL TAX Y
❑ Iherebyaffirm thmlhaveacenificat<of consent to self-insurt,ora cenificam of PIX RES-PERTRAP / RECEIPT
Workers'Compensation Insurance or a cenilied copy themof(Sec.3800,Lab C.)which PARK FEE Y N
rovers all employee's under this Permit. S-FA.SYSIEM-I INC. OI1T ECEI p
Policyp BUILD G DIVLAON FEES
CompanyGAS-EA.SYSTEM-OVER E PLANCHF,CK FI-B Z
C] Caddied copy is hereby famished.
❑ Certified copy is filed with the city inspectioniv GRBASEdNDUS"kRL T INTE EPTOR GRADING FE
CERTIFICATE OF EXEMf0NNCWEO
RKERS' GREASETRAP SOILS FECOMPENSATI(This acction recd nothcompldedronehandeddollars(81 ) SCWER-SANIT Y-STOR ;A.2WFT. EN 'E
less)I cenify that in th performance thh this permit is issued.l shall WATER � T W/VENT/ELECTR
not employ any peau^ in any matmerme subject to the WorkersPAICompensation laws of California. Dam WATERS!
EATING le Haveipt#
Q z Applicant
z 0 NOTICii'FOAPPI.ICANT:ILafiermAingthis Cenificateof Exemption,yau should EW RESIDENTIA.PLMR. SQ.FT. TOTAL:
became subjat ro the Wo&&s Compensation provisionsof the labor Code,you mus,
> forthwith complyy with such provisions or Nis pemm,shall be Claimed revoked. BUILDI FEE
1 (] CONSTRUCTION LENDING AGENCY SEISMI.FEE
I hereby affirm than there is a contraption lending agency for the performance of
U Z TOT ELF. IC FEE
O the work for which this Permit is issued(Sec.309].Civ.CJ
Lender's Name
u" F Lenders ndareax QTY. MECHANICAL PERMIT FEE PLO BIND FRE
U I certify that I have read this application and sm a that the above information is MECI ANICAI.ITP
>" W c rrect. Iagree m<omply with all city and county ordinances and state laws printing to PERMIT ISSUANCE
building emistrut ion.and hereby umhmise representatives of this city to enter upon the CONS RUCTION TAX
U Z above-mentioned pnrperty for inspection purposes. ALTER OR ADD TO MECI.
(We)agree to save,indemnify and keep harmless Ne City of Cupenlno egainm
liabilities judgments.costs and expenses which may in any way acme against said City AIR HANDLING ON]'1'(TO 10.000 CFM)
in conwquence of the granting of this permit.
AIR HANDLING UNIT(OVER I(1,0W CFM)
Signature of AWlicam/Conha<mr Date EXT IAUST HOOD(W/DUCT) PAID
I IAZARDOUSMAMRIALSDISCLOSURE HEATING UNIT(TO 110,000 B'TU) DateRc¢iptp
Will lM1e applicant or future building Occupant score or handle hmardous material HEATING UNIT(OVER 100,000 BTU)
L
ed by the Cupcnino Municipal Code,Chapter 9.12.and the Health and Safety
ection 25532m)Y VENTILATION FAN ISI NGLE RESID)
❑Yes ❑No
ISS %IIIATE
Will C] licanmrfummbuildin fusee wrdeviceswhichemil BOILER-COMP(311P OR 1W.(KKI RTU)
pp g«cupan quipmen
u,air ecopea inama as defined by the Be,Area Air Quality Management BOILER-COMP(OVFR 100,an 111 C MAR'1 1r AR
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
haver d nic baaa.dova me tiaE o mire cmx andtt Chaprc 6.95 of Ibe OI I Y U� LUYtHia llealth&SaretyCWe.Sections25505,25533and25530.lundersladmthal
ilding does not curently have a mnan4 that it is my resonsibility to notify the
nt nr Ibe requirements which must le met prim to issuance of a Cenificate of
ncy. IFor authonded agent Data TOTAL: ISSUIiU BY: