27246 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO. BUILDING-ELF.0FRICAL PERMIT NO.
ING-MECHANICAL f� /� C
BUILDING DIVISION APPLICATION/PERMIT PLUMBBU1LDINGPROJECI'IDENTIFICATION L 46
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
/ 9G2N HO/-J'rSl -AD UNIT# LOT« I��V
OWNERS NAME: PHONE: CONTRACT'OR'S NAME,: LIC NO: )
GDdD 5AMA21T�Ju,I LHOQ(61 2S3-07xr/ $ cLF NIC CONTROLp
RCHI'I ECT/ENGINEER: LIC NO: ADDRESS: ❑
'CONTACT: PHONE: BUILDING PER
LAT2/N
4.QY SGE2
R 738'-243 MIT INFO
QTY. ELECTRIC PERMIT FEE yLDG ELECT PMI B MEC
PERMIT ISSUANCE .4
LICENATI
SED CONTRACTOR'S DECLARON APPLIANCES-RESIDENTIAL LF
M-Z I hereby affirm that l ton licensed under provisions of Chepter9(commencing with �'10 SCRIPTIO
�00 Section 900(oof Division 3 of the Business and Professions Code,and my license is in PANELS I
CWF full Ease and effect.
FZw License Class Lic.# UPT0200AMPS
Q'a Dale Contractor
rn�to 201-IUf)AMPS
7,ONZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA b/SQ.FT.
0 Z_r) I understand my plans shall be used as public records.
Ftite SIGNS ELECTRICAL
QY E, Licensed Professional
Yedtta OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
k3�N I hereby affirm that I am exempt from the Commcmr's License Law for Bic
uu11 following reamv.(Section]031.5.Rosiness and Professions Cale:Any city or county TEMP.METER OR POLE INST.
F which mluires a permit to currome,aheq improve,demolish,ser reps..any structure
5 'T� prior to its isaware,aho requires me applicant for such permit o file a signed statement POWER DEVICES
ca;_O0z that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aKCLL 9(commencing with Section 7")o'Division 3 ofhe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that be is exempt herefrom and the basis for alleged exemption.Anyviolationof OUTLETS Section 7031.5 by any applicant for a permit subjects Be applicant no a civil penalty of DUFIXTURES l
Znot more than five hundred dollars($500).
KFPo I,u,ownemf thepro n yemp y g Pe...lian, NEW RESIDENTIAL ELECT SQ.FT.
44 pc y,orm to ees with wages contSTORIES 9'YPE CONSTRUCTION
a5 Il dmhework,and there Canonical
anLi cense Law
a(Sec.to wo Rosiness
and Professions Code:The Contractors ow h.law does not apply tort owner iof
s
propeey whobuilds omphed suthereon,and whow ensuch work himselforthroubhh:s
owlemployees providedinorimprovemch ent is vid whin not intendedoroffered the owner. OCC GROUP RES.UNITS
howeer r.will avec a burden
of proving that
he did noneyw or impmve for purpose f T
builder will have the buNen of proving thm M1c did not build m impmvc for purpose of
sale.).
❑ I,mownerufthepmNe y,amercluavelyconuaciingwithlicens conuactorsm QTY. PLUMBING PERMIT FEE ROOD ZONE APN
construct the project(Sat.9014,Business and Professions Code:)Vol,Contractor's
Licemclawdoevnmapply to..o ,,erofprtpenywhobulldvorimproves0erean,and PERMIT ISSUANCE
whocontmets for such projects with acon4acmrts)licensed pursuant to the Contractor's
Licesew Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt ander See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATIONDECLARATION DRAINS-FI.00R.ROOP,ARG,COND. SCHOOL TAX Y N
❑ Thereby affirm that lhave
mence..cludidcorsemto ul(Sect re,or Lid,C)which FIXTURES-PER P RECEIPT#
coverer11en nsmiowlermi,poracenifiW<opytherrof(See.3R00.1.ab C)which PARK FEF, Y N
ycovers all employee's undcnhis permit GAS-EA. S -1 .4 OUTLETS RECEIPT#
Col
Policy# BUILDING DIVISION FEES
Company GAS .S :M-OVER 4(EA) PLANCHECK FEE
❑ Celified copy is feed with ecityhed. s
❑ Gasified copy is filed with the city inspection division. R SEANDUSTRL S CEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE' / SOILS FEE
COMPENSATION INSURANCE
('Oti'x.1iunneedam becompleted iftheprmit is forone hundred dollars(5100) SEWER-SANT ARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the pelf-wrower,of the work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ any person in any manner sit w m become subject to the WorkersPAID
Z Compen.wbon Law,of California. Date $WATER SYSTEMTREATING Dale Receipt#
Q Applma r
z O NOTICE TO APPLICANT:If,after making this Cerificme of Exemption,you should RESIDENTIAL PLMIL SQ.FT. TOTAL:
rIZ) Income saffect to the Workev,Compensation provisions oflhe Labor Code.you must
tet^ 7 forthwith comply with such provision or this permit shall h deemed invoked. BUILDING FEE
per, Q CONSTRUCTION LENDING AGENCY SEISMIC FRE
a z Ihereby affirm that is a construction lending agency for the performance of
U O the work for which this permit is issued(Set.309'!,Civ.C.) TOTAL ELECTRIC FEE
Isnder's Name f
QU Lcnder'.s Address MECHANICAL PERMIT FEE PLUMBING FEE
} D.d I certify thea,I have read this application and start that the above information is
correct.l agree in comply with all city and county ordinances and state law,relitingmPERMIT ISSUANCE �. MECHANICAL FEE
building cnnstr ismer, rad hereby uuthn,ce representatives of this city.care,apon rbe
U Z above-mentioned property for inspection puryoees. ALTER OR ADD TO MECH. 1 CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against a
Iiabiliries,judgments,costs and expenses which may in any way secure against said City AIR HANDLING UNIT(TO 10,000 CFM)
in coneque ce ofill gr rxrmngofthixpwmit.
�l�N. "// ,i,�/l�(/Iit.-,,` 1r1-9y AIR HANDLING UNIT(OVER 10,WOCFM)
Signatumof ApplicantaComractor Date EXHAUST DOUG(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HI?A'I'ING UNIT(TO IW.WO BTU) Dae Receipt#
Will the applicant or future building occupant store or Wide hassrdous material
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I OO,oOB BTU) TO
Code,Section 25532m)?
ED Yes ;e No VENTILATION FAN(SINGLE RESID)
Will the
all"applicant
erandsfuture s building occupantuse AreaAen Quality
Mwhichemit
BOILER-COMP ODE OR HI0,0(AI BTU) ISSUANCE DATE
h mr is..ur sir contaminants n defined by the Bay Arca Air Qualify Management BOILER 100,000 BTU)
Dislrim? P
13 Yes 'IV No NEW RESIDENTIAL MECH. SQ.Ff. �1�
411)
Lbuilding
read the havardous poseth s«gairemed,under Chapter 6.95 of the /�OII
Health Code,Sections 25505.25533and 25534.1 ondenaand shut II// 0 7
does nut currently have a tenant.that it is my responsibility to notify the C�]�.V ` ,
he requirements which must M met prior to issuance of a Certificate of •,or,"agent Date l ISSUED BY: 1 1 v
OFFICE