27208 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - BUILDING-ELETRI AL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECRANICAI. A OO
o
BUILDING PROJECT IDENTIFICATION L
BUILDING ADDDRREESSi: � SANITARY NO. APPPLICATTIIO'NS.UBMITI'ALDATE
UNIT 4 lA.i� LOT#
OWNI:R$�Ah1E��/B I 40Mr IfONE0� CONTRACTOR'S LIC NO: N/C l CO��I�__RO\LLCM
• ARCIIITE�ICf/ENGINEER: '•V/ S (LICNNO: ADDRESS: ❑
CONTACT: PHONE:
QTY. 13LECTRIC PERMIT FEE BUILDING PERMIT INFO
�/r��
PERMIT ISSUANCE aaL�Q, �L`P( \CSI•
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION
QWz Ihereby affirn that l an licensed underproviaionsof Chnplm 9(cammencing with
ts100 Section]00d)ofect. on3of the Business and Professions Code,and my license is in PANELS
_�ttZda full Live
rceandeffecr.
fzi License Clms o.p UP T02(p AMPS
va<y Dae Contractor 201-1qp AMPS
Z FOyz ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.FLOOR AREA 5/SQ.FT.
shallh u
I understand my plana sl sed u public rtcmda.
O z—a
r h t, SIGNS ELECTRICAL !Vw
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL.CIRCUIT/MISC.
W O: p 1 hereby off that I urn exempt front the lemmas Code:Anse law for the
W3Oya follwhnwingmasoa ermit to constru Buslter,i pr Professionsh,or
city or county TIiMP.MEILR OR fVLF.INST.
which requires a permit re construct,alter,improve,demolish,or repair any srammon
C �7 that hosirmaded parcnstrui res the visams.for esuch Cmarun's file a License
statemrnr POWER DEVICES
Co that he is licensed p�rs ction the provisions of Ne[be Bu nors License law(Chapter
ain, 9(cnmmencin with Smtiun]0(Xp of Div the Business end Professions Cade SWIMMING POOL ELECTRIC
WM (commencing ) VALUATION
m—rn othat ohei.1.5 by therefrom and the basis mfor the
cts thedexemant to civil piolty of
Section IDhu5Iv anmciand dontfor a 00). suhjeas the opplicvnno vcivil penalty of OUTLETS-SWITCIIFS-FIXTURES J`Jb
t morethen fivehundrcaddlor my emp. NEWRESIDEINFOALELECIt _S FT.
p� ❑ Lhnwrk,andeestruchum is n empended orofwaguasalei( to m. (kiBusinem, STORIES TYPE CONSTRUCTION
L _ will duthewmk,Carl
eae Con rmarremicense Law
ed dors notsale(SmAM4,Business
and Professions Cade:The improves
dremors License Law dces not apply to an owner of
propmywhobuilds
providmpmveath improvements
am n intuch work Nmffendreffor through his OCC.GROUP RES.UNI IS
neer,the
g cars that such improvemmtthin not eyearofr or offend for the o e.If,
however,the building burden
o pment is hila within one year of c prove for pu owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,as owner of]he property,am exclusively contracting with licensed contractors to QTY. PLUMBINGPERMIT FLOOD ZONE APN
construct the project(Sm.7004,Business and Professions Cade:)'Me Commader's PERMIT ISSUANCE -
License Low does not apply to an ownerof prcperry who builds or improves thereon,and
who convects for such projects with acontractor(sJli ceaseApursuunuofhe Contractor's Ai EA
License Law. ( ) FEE SUMMARY
❑ 1 nm exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE PEES
SANITARY Y N
Owner Dom RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,ARLA,COND. SCHOOL TAX Y N
❑ Ihcreby nfOnn thmlhave acertificete of consenno self-insure.era certifeme of RECEIPT#
• ormit,orkera'Com ce
tion Insurance ma rtifiedc FIXTURES-PER TRAP
era all empYee's under this pespy thermf(Sm.3g0o,Lab CJ which PARK FEB RFCCIPT# N
GAS-LA.SYSTEM-1 INC.4 OUTLETS
Policy Is - BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK LLE ass'sssss �
❑ Cerifedropyisherebyrumimml.
❑ CenifieJ copy in Bled with the city inspersion tlivisinn. GREASHINDUSTRIL WASTE INTERCEPTOR GRADING FEL
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBTRAP SOILS FEE
COMPENSATION INSURANCE
(Thiaeection need not bearmplmcd ifthe pmenit is for ons hundred dolt.($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Ice"ifytha in the perlomme,of the work for which this permit is issued,lshall WATER HEATER WIVENIELECTR
not employ any person in any customer so as to become subject to the Workers' PAID
z Grmpensurien Lawaof CvlifomIRFA
ia. Dole WATER SYSTEM/ TING Dare Reccipt#
Applicant
0 NOTICE TO APPLICANT:lf,nRcr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FIL TOTAL:
(q become subject to the Workers Compensation provisions of the Labor Cade,you must
I ; forthwithcomply with such provisions or this permit shall IN,deemed revoked. BUILDING FEE ` r�
Wz CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 O
Iherebynffirn tha lard,iso cmmatim lending agency forth,performance of
IN Q
U the work for which this permit is issued(Sm.309],Civ.C.) TOTAL: ELECTRIC FEE
Lenders Nome
0 F Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE All L69
U 1 certify that 1 have read this application and state that the move information is
correct. le rm to comply city yo g MECHANICAL FEE
g pywith all cit rM chum Ninvnces and state refining m PERMIT ISSUANCE
�"' fn building construction,and hereby authorize representatives ofthis city to enter upon the
U Z hove-mentioned proprny for inspection purposed. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupenino against ^
Iiabilitio,judgments,costs and expenses which may in any way acme against raid City AIR HANDLING UNIT(TO 10,000CFM)
in ns n of the granting of do,permit.
�� I
re mt
AIR HANDLING UNII'(OVIiR10,000CPM7
Signatuof Applic /Conran r Date EXHAUST HOOD(WIDUCT) PAID
HAZARDOUS MAT RIALS DISCLOSURE HPAI'ING UNIT(TO 100,OW BTU) Data Receipt#
Will the applicant or fourc building nccupnnt store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TO
m defined by the Cupertino Municipal Code,Chapter 9.12,and the I lalth and Safety
Code,Section❑Yee 2(n? ❑No VENTILATION FAN(SINGLE RESID)
Will the licamt m lumm oiliinomu BOILER-COMP(3HPOR 100,000BTID ISSUANCE DATE
app g pantuuequipmem mdevirra whichemit
•bvzardous air communama as defined by the Bay Area Air Quality Management BOILER-COMP(OVER atri100,000 BTU) T
Gabon? ❑ p
Yea ❑No NEW RESIDENTIAL MECH. SQ.IT. r %
I have ,
the InstructionsInstructions mutenals rtyuirtmems anile(Chatum 6.95 of the SAN 2A�
California Health&Safety Code,Sectima 25505,25533 and 8534. I understn a the 1995
if the huilding dces not curten0y have aten.nt,that it is my responsibility m notify the
C/+ 1 a71�
mcupnm of the rcyuircmcnts which must o met poor to issuance of a Certificate of /1 Y
Occupancy. r
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE