27578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO II ILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PRo,IE5 O
CP IDENTIFICATION J o
BUILDINGADDR X 'V`� ` ` ` SANITARY NO. APPPL'IICATIIOONSUBMITTALDATE
lW` UNIT# LOTH
OWNER$�f PHONE: All;CO ACTOR'S NAM LICN
`J NIC CONTROL p
ARCHITECf/ENGINEER: LIC NO: DRESSSJy ❑
D
CONTACT: PHONE: QTY. C T— FEE BUILDING PERMIT INFO
BLDG ELECT P N0017
'- - Y C PERMIT ISSUANCE TY.,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M%z I hereby uffrtm that l am licensed under provisions of Chapter 9(commencing with JOB DESCRIPFION
W 00 Section]OW)of Division 3 of the Business and Professions Cale,and my license is in PANELS
WF. sell farce and effec �/aE�1��{4 1
<UU tc' Class�6— Lis.If ,�/e+ l� ` UPT02WAMPS
to Dam Comnaor 201-100 AMPS Y 1 Y
Fy Z ARCHITECTS DECLARATION SQ,FT.FLOOR AREA E/SQ.FT.
Z Om_ OVER 1000 AMPS
O Z_O 1 understand my plans shall Be used as public records. l
P'' sal SIGNS ELECTRICAL. L�1TT`
<Y5j Licensed professional
:4 _J
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x W V I hereby affiun that I am exempt from the Contrractor..,License Law far the
+31+-vFi following reamn.(Section 2031.5.Business and Prnfessiom Cade:Any city ar county TEMP.METER OR POLEINST.
F-0< which requires a permit m convect,alter,improve,demolish,or repair any structure
,,Y7m its isoa,vc..l,om Ihca licem lixwah nolileasi dsaimancat POWER DEVICES
poor genre rp peters gne
,5Q0 that hero licensed pucsuam to the provisions of the Contractor's License Law(Chain,
""r XX 9(connnenuingw'nh Section 2000 of Division 3 mine Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
X.V�ti Or that he is exempt therefrom and the basis for the alleged exemption.An,smi um of —�
Y Section 2031Sh applicant I subjects I tmacivil Ityof UTLETS-SWITCHES-FIXTURES
F.Z< y any app icon pe(mi su jec s pp icon pens 11..1
not more than five hundred dollars F$500). NEW RESIDENTIAL ELECTR SQ,FT. STORIES TYPE CONSTRUCTION
2'Fo ❑ Lusowneond the structure is
for tic(sole compensation,
y3°. will dothe wons andthe he Concesnots Licensor Law
apply(See Th W.Business
and Professions lCodedsm The Conaecmrs rid%ho Law uch not apply io as owner of
pmpenywhobeiIdsserimpravesthereon,andwboduesouchwork omuefm through Ns
_ OCC GROUP RES.UNITS
emr,th ees,provldW t improvement
not ear frompffcad forthe owner If.
howcer ,will have
brimpmvementi that he within build oimprove forn.purpose
builder will have the burden of proving that he did not build or improve far purpose of
xme")' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as nwnen/(Sm.
excluv contracting with licensed rnntruaorsm
Onsauct the projaFL Business an oreasiona Cale)The Camano "LimasLawdoesanownerofpmpeny builsorimprovcs thereon.andPERM ISSUANCB -
whocmametsfor ,withawnt.ton,)Iim.. pursuant mthe Comraam'sLiccnxe Lnw. ALTER- IN VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt I'C for this reason BACK F PROI CT.DEVICE. OUTSIDE FEES
SANITARY Y N
Owner Duro RECEIPT#
. 0 AREA
WORKMAN COMPENSATION DECLARATION DR S-FI R 0
.COND. SCHOOL TAX Y N
El them affirm tWtlhave acenificam of consemmulf-inmre.or ertificate of FlXTUR -PERI' PCIA RECEIPT#
Workers uniformitarian Insurance or a certified copy themof(Sec.38W,La C.)which PARK FEE YN
CLIF
covers emund
ployecser Wepcnnit. GAS-EA.SYS -1 IN 5 R '
Policy BUI 'G DDTVIIVIS) NfEIS
Can Y GAS-EA.SYSTENFOa(EA) P1.ANC1IECK
11C ificsimpyi,herebyhournishod.
❑ CriiEedcopyisfiledwiththe ins do i 'sion. GREASFANDUSIRI iRCF OR GRADINGFEE /J
CER'F]FICAIEOFION FROM WO E GREASF,TRAP SOILS
COM ION INSURANCE
'Or"ectionn J it mplemdiflhe permit o94andredd as($100) SEWER-SANITARY-STORM BA.2001-1'. ENER E
odes
I oilythal I nrmanceof the w�rk\p V is panni isomd.lshall WATEREIENIERW/VF.NT/ELECTR
tun amps, any pcis n any man so a some stf m In the Workers' _ PAID
CO.,-lion Lows of fnOy um \\\ WATER$YSTIiM/1'RLATING Dae Ren t#
Z Applicant
Z 0 NOTICF.T APPLICANI':ILafmrmakingthix Ceniticamu i emption.youshauld NEWRFSIDENTIALPI.MH. SQ.1T. TOTAL:
I" y Become so a to the Worker's Compensation provisions o he Labor Cade,you must
forthwith con ly with such provisions orchis pe on she maredmvoked. BUILDING FEEPitBaa
0. Q CONSTRUCTION LENDIN AGENCY SEISMIC FEE
� Z 1 Bemhy of that there is a common, le ing agency for the pe,farrwncc of T ELECTRIC FEE
U O the wok for whic his permit is issued(Sec.3 ,Civ.CJ
Lender's Name
D"' F Lender's nddmss QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have NqdI this a 'anon and stere that the above info(maion is MECHANICAL FEE
>" Cl] Comma.l agnmot comply wit ryand county cognitions and state laws relating m PERMIT ISSUANCE / �—
buildingeonstruaionr and hereby authonee representative ofthis city soccer upotvbe -
aawn-mentioned rtfor ins ,tion ALTER OR ADD TO MECII. CONSTRUCTION TAX
U z Proper pe ramous.
(We)agree to save,indemnify and keep harmless the Cirycr eagansts against
liuhiliti gmm�is.coxLc unJ ecreacen whiehmvy sonny way ucerucvguinst said City AIR HANDhINO UNIT(TO IO,gl)CFM)
.ugne sof the gmminI, this'orroh. f�l l—/�
AIR HANDLING UNIT(OVER 10,000CFM)
Si,rair eof Applicant/Comruc r Dam EXHAUST EIOOD(WNUC) PAID
tie
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.00a BTU) Dan Receiptp
Will the applicant oifuture building occupant store or handle hae(dous material HEATING UNIT(OVER 100,00t0 BTI) TOTAL:
as defined by the Cupertino Municipal Calc Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE AATE
Wilhhee licantnrfaurebuildin mu ctrl ordeviceswhich emit BOILER-COMP(JHYOR 100,000 BTU)
oP saceavan egnirm
,liiIMn
doas air contaminam as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,0(10 BTU)
❑Yee ❑No NEW RESIDENT'IAh MECH. SQ.Ff.
PAID
1 have revel the hmmdous materials le,s ircmem.under Chupmr 6,95 of the
Culifnrniallcnith&Snfey Gde.Seoionn25505.25533imd25530. lundersomdmin JII a�
Hine building does not currently have a tenant,that it is my responsim bility notify the /A VL
Occupant of the requirements which must be met prior to issuance of a Cembcae of
Dec araney. '
Owner or amhonzed vgcm Dam ISSUED BY:
�I(JI�`r0'7t1i I IN(!
OFFICE