27481 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUIL"ING.ELEcrnBCAL PERMIT No,
APPLICATION/PERMIT PLUMHING-MFIDENTIFIC 27 /I8
BUILDING DIVISION II1111.DING PROP'.CT IDENTIFICATION L !•+0 1
BUILDING ADDRESS: - SANITARY NO. APPLICATIONSUBMITTALDATE
2� UNIT is I �2v7'cS
OW 1 PII B: CO 'R OR'S NA G' N/C CONTROL#
A CHITIS /ENGINEER: LIC NO A R S ❑
CONTACT: PHONE: Y° j,x ,.
o'�
QTY.„ate f ELECTRICPERMIT 17EE'= - BUILDING PERMIT INFO
O�/: Q
PERMITISSUANCE
BLDG ELECT PLUMB MEC#
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pKZ Iherebyaflmothat l am lice.sedandertimishimn.farquar9(cummcncing with JOB DESCRIPTION
u100 Scotian 7001 Division3.fthc Bminusand Code,end my license is in PANELS
F fc, (ell fome a az UP
<Z, L i'rnse ClnS.e'�(`CLi
onvey es201 T02W AMPS
1000 AMPS '
.SFO 1 ^TS DE ARATION OVER IOW AMPS SQ.FT.FLOOR ARBA $/SQ.FT.
O Z—O 1 unJenf sed public recoNs.
Fq'yF j SIGNS ELECTIUCAL
g ,, Licenx rofes' ryl
g ��{ I and BUILDER DECLARATION SPECIAL CIRCUIT/MISC�_
0.F 1 b ry li that 1 nm exempt from the Contrucwr's License Law for the
nJ'3lL m fidlowi g rt o Section 9031.5,Bsmrse and Rnfessions Code:Any city or c.unty TEMP_MEIER OR POLE INST,
t��� which requ alkrmitm consumer,.her.improve,demolish,or repair,any structure
f N� pri.moik issuance,also requires the applicant for such permit o rile a signed statement WEROEVICfS
that he is licensed pursuant to the provisions of the Comancmr'a License Law(Chapter
dkp�- 9(commencing with Section 7")ofDivision 3 of,he Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
,,that he is scruid flicofionind the Isis(myheullegedexemptim.Any violation.( DUTLBTS-SWITCHES-PI%TURPS
tZaSection'l031.5 hyuny applicant mrnpit crmsubjects,he.pplicxnfto.civil penalty of S
f20 not more than five hundred dollso,S500).
CF_o ❑ 1,s.wnerofthepropeny.ormyemployeeswithwugesstheirsolecomprnsano NEW RLSIDENTI E _SQ.FT. STORIES 'TYPE CONSTRUCTION
y3e..9 will dome w�rk,rnJthe struttare isnot Intended.mffcreJ fn...le(Scc.TM4,Bus1@
and Professions Cale:The Conlmc or'a License Law does rot apply to un owner f rm 1A,
property whobuildsorimprovesrhemon,and whodaes such wm
ort himelforthugh s
howemployees,provided Nat such improvements arc nmmendederoffared forxle. OCC.GROUP EH.PN
ever,the building or improvement is sold within one yearofcompletion,rhe owne- /
builder will have the burden of proving that he did not build or improve for pary: T AL:
sale.). y;
❑ I,as owner of the property,nn exclusively contracting with licensed contract QTs S, PLUMBING PERMIT FEE I1,00D ZONE
construct the prided,(See.9(144,Business and Professions Code)no Connector's
LicenseLawdoesnm apply conn ownmofpropetty whobuildsorimproves Hereon,and PERMIT ISSUANCE
who contracts Law.forsuch pmjecnwiNacomrador(s)licensed punuwmN<Conuacmr's ALTER-DRAINS, -WATER PEE SUMMARY
[,to so Law. EA)
❑ I am exempt under Sec. ,H&P C for thio reason OUT.PUL FLIT.
HACK FL? 0TECT.DEVICE SANITARY y Y N
Owner Dao S-FLOOR,ROOF,AREA,COND. RECEIPT'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
• c❑ I hereby affirm that l have certificate ofconxm mself-inme,.aacenificamof FIXTURES. RI?CEI"#
PER TRAP
Wmken.'Compcnsntiun lnsu�ryanc�eeo�raccniEed copy thereof(Sec.38W,lab C.)which PARK FIiE YN
Pour,411empfin� yp4(y yl/ .meq DIVISION
LL`y h C6 L GAS-EA.SYSTEM.I INC.4OUTLLTS BUILDINGRECEI T#FEES
Company �'f 'JJ(sjj w� GAS-FSA.SYSTEM-OVER 4(EA) PLANCHECKFEE
❑ Certified copy is hereb stied. h s+
��
�'Cenilied copy is fled with the city inspection division. GREASIWFE
NDUSTRI.WASTE INTERCEPTOR GRADING E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTMP SOILS FEE
COMPENSATION INSURANCE
(Thisacedom need..,bersmpleted limit permit is Income hundred dollars(SIM) SEWER.SANITARY-STORM EA.20011. ENERGY FEE
less.)
I certify Nat in the performance ofthe wort forwhich this permit is issued,l shall WATER HEATER W/VENT/ELECIR
not employ any pence in any manner so No to become subject to the Worker' PAID
Compenxutien Lawsof Celifomio. Date WATER SYSTEM/TREATING Dme Receipt#
O z Applicant
z . NOTICE TO APPLICANT,If.after making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
H hccome,subject[.,he Worker's Compensation provisions of,ha labor Code,you must
� , f.Mwidt comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC ME
^a Iberebyaff„m that there iso consvuction lending agency for the perfnrmanceaf TOTAL: 0� iLECI'NIC FP.F
U O the work for which this permit is issued(Sec.301 Civ.CJ
Lenders Nome _
w0 F Lcndcea Address QTY. rMECIIANICALPERSu'r, FEE
PLUMBING FEh
U I certify that I have read this application undulate that the above information is '
correct.l agree to comply with all city and county oninances and sate lows relating to PERMIT ISSUANCE MECHANICAL PEE
F” IA building construction,and hereby suNodu represermad esof Niscity toenlerupon the CONSTRUCf10N TAX
V 7 above-mentioned property for inspection purposes ALTERORADDTOMF.CIL
�7 (We)agree to Nave..jiggle y and k nrrnless a City of Cupertino.,.lost
rapidle,,judgments ich may' ywayacerue.g.ustsaid City AIR HANDLING UNIT ITO 10,000 CFM)
in consequence of N' .nit.
AIR HANDLING UNIT(OVER 10,007)CPM)
Sig cont/ Irwin, ate EXHAUST HOOD(W/DUCI)
PAID
IAZARDOGS MA'fFRIALS DISCLOSURE HEATING UNIT(10 Potato N'TU) Data Receipt#
Wills plicismi..a buillCess,Chapter
handle,Health and Softy
s defined by the Cupertino Municipal CMe,Chapmr 9.12,and the Health end Safety HEATING UNITOVER 100.0101)BTU) TOT 1.:
Code,Section 25592(x)1
ED Yes 11 No VENTH.A'TION PAN(SINGLE RESI)) Lit r"
BOILER-COMP GHPOR IMOMBTU) IPVXC DATE
Will that om ucomencant umrc building h,the
nBay Auipmenmuality es Manage ant �/ D
Di'monus it conauninatne use delinal by the Bary Area Air Quality Management BOILER-COMP(OVER 110,000 RTU)
Dixulml JAN 2 7
❑Yes ❑No NEW RI5IDENTIAI.MECII. SQ.FT. 199
1 have real the hazmdous materials requirements under Chapter h95.f the 'Jy
California HwIN&Safery Cale.Section,25505,25533 and 25534. 1 undersand Net
ifthe building docs not currently have.tenant,that it is my responsibility to notify the '�Ut LUI''ttJJIrq(I
occupant of the requirements whi h must be met prim to iotense of a Certificum of
O cup cy.
Owner or uuth.rrsed agent
Date - TOTAL: ISSUED BY:
OFFICE