27725 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILBINU-hLECTRICA, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT -PLUMBING-MECHANIC 11 27725
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
���• UNIT LOTH
OW MR; h ♦ PHpyE:A CONIi~R'S NAME: y LIC�:
S E9 NIC CONTROL#
RCHI'IECI'ANGINEIiR: \4x/PL1_CNN]O_:: ADDRESS:
�l0 S S.S :
El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INTO
BLDG ELECT PLUMB T1ECI1
PERMITISSUANCE ❑ ❑ ❑LICE
mthat SEDamt CONTRACTORSunderpDECLARATION APPLIANCES-RESIDENTIAL 3�Y� _tons.
1400 I hereby 70004 ofrm]hal am dowsed undcrard Pi onsofChapter and mmecense with 11�►a—
�n00 Section 7lp0)of Division 3of the Business and Professions Cods,and mylicenm ie in PANELS
g0.IF full farce unAeff r1. .L Ga UP PSA
Fz aV License Cl ss e•�' Lic.# ''f`�'
m6y D' Commcor N 201-1000 AMPS
0 FOyARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOORAREA E/SQ.FT
1 .
O Z"q understand my plans shall he used as public records.
ee E'W SIGNS ELECTRICAL
gy7� Licensed Professional
IaOWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
ippi(S,,Owu I hereby affirm Thal I ma exempt from the Communal License Law for the
m3am¢ following reason.Clooirm703L5.Business and Professions Cade:Anyonyarcounty TEMP.METER OR POLE INST.
.] which requires.pemat to construct,sher,improve,demolish,or repair anysuucture
M>-� prior m its iss.sub o.,.a.the applicant rm
t for such peit to BleuignMstmement POWER DEVICES
t q p p that he is licensed pursuant to the provisions of the Con otaton's License Taw(Chapter
ere s
9(commencin with Section 7of Division 3 of Ne Business and Professons iCade SWIMMING POOL ELECTRIC
oLL B 11(#1) ) VALUATION
y _to or that he is exempt herefrom and the basis for Ne alleged exemption.Any violation of OUTLETS�SWI'TCHES-FIXIVRES
F_0a Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
t Mo.'ban five hundred dollars($50(d. NCW RESIDENTIAL ELECTR S .PT.
C m n❑ 1,esownendthcpropeny,ormyemployecswiNwag<ses lheirsolecompnlmtion, —SQ,F]'. TYPECONSTRU ON
y will do the work,and the umclue is not intendedoroffered foraale(Sa.7094,Business
and Professions Cade:The Cnmrai is License Law does not apply to an owner of
pmpeny who builds m improves Thereon,and who docs such work himself or through his
ownemplayocs,provided that such improvememsarenminrondedoroffered forsale.If, OCC.GROUP RES.UNIT'S
however.the buildingor improvement is sold within one yearn(completion,the owner- TOTAL:
builder will have Ibc huNem of proving That he did not build or improve for purpose of
le').
ElI,asowncroftheproparty,amexclusivelyconvactingwllhlicemedcnnractnrslo QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.71004,Business and Professions Care)The Contmmor's
License Law dos not apply to an ownerofpropery whobuilds orimpowes thereon,and PERMIT ISSUANCE
whoconlructs for such projects with aconvactor(s)licensed pursuant to the Contmctole ALTER EA
License Law. ( ) FEESUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE
DN
(honer Date RECEIPT#
WORKMAN COMPEbISATION DECLARATION DRAINS-FLOOR,ROOF,AREA,CONDI. SCHOOL TAX Y N
❑ thereby afRrm that l have a certificate ofoonseneto self-insum,or a onificate of RECEIPT'#
WorkeW Compeaution insurance oraceniEed copy theroof(Sa.3800,Lab C.)which FIXTURES.PER TRAP PARK FEE Y N
coven all employees under this permit GAS-EA.SYSTEM-1 IN OUTLETS RECEIPT#
Policy# BUILDING DIVISION MIS
Company GAS-P- .SYSTEM- 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished
❑ Certified copy is file with the oily inspection division. OREASEA 51,61U.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G .TRAP SOILS FEE
COMPENSATION INSURANCE
This section need not he completed ifthe permit is foronehundre dr.od
SEWER SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I eerily that in the pertornwwe ollhe work far Which'hiepermi'i'I WAT[R fll'ATf:R WNF.NT/GLECTR
not employ any person in any manner ser as to become subject to Ih PAID
Compensation Lawsof Co' Mia. Date WATER SVSTF.M/IR TING
Dae Recciplq
0 7-+ Applicant
O NOTICE.TO APPLICANT:If.after making this Cerificam of P.xcmption,you hnulJ NCW RCSIO PI B. .FT. TOTAL:
V] became subjauolhe Worker's Compenmtionprovisionsofthe Lobar Coda ya mull
� ; forthwith comply with such provision.phis permit shall bedecmed revolt as BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.z 1 hereby affirm that them is a construction lending agency for the performance f
U O the workfor which this permit is issued(Ser.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name PLUMBING FEE
O F Lender's Addreaa QTY. MECHANICALP IT FEC
U 1 comfy that T have rend this application and state thin the above inforion i
nms
>" W conal.I agree mcomply withal]city and county containment and nose lawsmlmingm PERMIT ISSUANCE MECIIANICAL FEE
UE-' buildingeominction,andherobyau'hodmrepmmnmdvesofthis<ity toenttt upon the CONSTRUCTION TAX
aborumentioned property for inspection purposes. ALTER OR ADD MECH."
(We)green,save,indemnify and keep harmless the City of Cupertino...inn
Imbili'ies,jud,romm,cons and expenseswhich mayin any way sccrueagainmmid City AIR HAND GUNIT(TO 10,000 CFM)
in can .arca of the gran ting of Nis .it.
NDLINO UNIT(OVP,R 10,000 CPM)
I - 4
/Iinemre of Applicam/Commcror Date [IS]IAUST HOOD(W/DUCT)
PAID
I(AZAR DOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Reccipt#
Will the.pplicunt err Tuano building ocontract store m handle hazurdous material ,
us defined by the Cupertino Municipal Code.Chupler9.12,and the Health and Safety III'ATING UNIT(OVER 100,000 BTU) TO'
Code,Section 25532(n)7
11 Yes ❑No VENTILA'T'ION FAN(SINGLE RFSID) �a
BOILER-COMP OLTP OR 100,000 BTU) R1 p IJSdNCEDATE
Will lair co icantar(u .,retired by the
Area Air .alit Management 1� /Y e
ismer?initiations air cmmeminunts us Defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0(10 RTU)
iaviet9 ®EC 2
❑Ye ❑No NEW RESIDENTIAL MECII. SQ.FT. ,994
Liffficb.ildni,
road[be hamMoas mmerids reyuiroments under Chapter 6.95 of the
thlth&irem Calc.Sections ho me,25533 and25334. 1undersandthat
dues not currently have.¢nem,that it is my responsibility to notify tl Y VrVf CHI1 the rtyuiremsts which nun be met priorm issuance ofa Cmificam of air I It,thorized agent Date T Al.: ISSUED BY:
OFFICE