27148 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMUTING.
APPLICATION/PERMIT PLUMBING-MECHANICAL n n 48O
BUILDING DIVISION - BUILDING PROJECTIDENTIFICATION L
HWELDING ADDI�SS�O � � SANITARY NO. APPALICATIO^N/S�U.B/yM�f'ITyAnLii
�DAI
T I LOTb
6b22 •l`J �CJ l
OW N E 30 CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
RCHITECT/ENGINEER: LEND: ADDRESS: ❑
'ovPACI': PHONE: QTY. ELECTRICPERMIT FEF. BUILDING PERMIT INFO
B% EISCf PLUMB MECH
a PERMIT ISSUANCE .� ?5L V
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑KZ Iherchyaffrm that lam licensed underpnwisinnsofChirpmr9(commencing with
WOO Section 7")of Division 3 ofthe Business and Professiors Code,and my license is in PANELS
C�IF-. fun boom and effect.<,W
FZW License Class Liu# UP TO 200 AMPS �/I
1<WDate Conlmalor 201-1000 AMPS
FyZ ARCHITECTS DECLARATION SQ.19'.FLOOR AREA $/SQ.FT.
ZOv— OVER IOoO AMPS
O Z,p I understand my plans shall be used as public records.
F.,F W SIGNS ELECTRICAL
Q��,'Jj Licensed l'mfessional -
E(tiWQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M "} •B3
"C) affirm 1 hereby affithat 1 am exempt from the Contactors License Law for the (/
1.kz1LLOm fcllowingrcasoo.(Section7031.5,Business and Professions Code:Any cityor county TEMP.MET FR OR POLI:INS .
Q which«quires a permit to construct,time,improve,demolish,or repair any strew¢
N�7 w its issuance,also re the applicant forxuch to file a signed statement POWER DEVICES
Prior quires pp Penni gn
,W<Ey that he is licensed pursuant,,the provisions of the C,,macwh License Law(Chapter
LEW 9(commencing with Section 7(M)of Division 3 of lire Business and Professions Code) SWIMMING POOL ELECTRIC VALUATI
orthatthat he is exemptherefrom and the basis for the alleged to violation of
YXI T'rn6 pin.Any TURES
FZQSection]03 LS by any applicant Gnaµrmit subjects the appli<anuo acivil penahy of
not more than five musical dollms(S50m. NEW BESIDE.NTIAL ELf?CTR aB SQ.FT. STORIs TYPl3 CONSTRUCTION
CF_ ❑ I,asownerofthepropeny,ormyemployecswithwagautheirsolccompenation.
M
3. will Jo Ne wak.and themmclure isnotimcndedmuffemd forash,Ser.701 ,Business
and Prolenions Cole:The Comaao's License Law does not apply to an owner of
pm mployo s,provi l provosthemprove wbt mnoac mora loroffe of dvough his
emplayms,providedthat xuchimprovemen rtnot imendedoroffered forsale:If, OUP RES.UNITS
however,the Irmidingor improvemeta is sold with ofaompletimi'thc.wier- TOTAL:
builikrwillhavetheburdcnnlprovie that d Id ar improve for purpose of
sal`')" QTY. PLUMBING PERMIT FEE APN
❑ Lasnwncrofthepropeny,amex .1 mractmgwithlicensedcontacmrsm y
construct[lie project(Seo.7144,Bro d Profession Code:)The Contractor's -
LicenseLawdoesnotapplytoanownerofp ywhe builds or improves thereon.and PERMIT ISSUANCE
who crmtmcts for such projects with acomac sUicensedparsumumthe ContactoLe
License Law,. ALTER-DRAIN&VENT-WATER(EA7 FEE SUMMARY
❑ 1 am exempt under Sec ,B&P C lar this reason BACK FLOW PROTECT.DEVICEOUT'SI OIs FEES
SANITARY Y N
Owner Doc RECEIPTa
DRAINS-PhOOR,ROOT,AREA,COND.
WORKMAN COMPENSATIONN
] Ihcre'ry affrm that lhave accnificam of coofcome DECLARATION SCHOOL TAX Y mm molt-insure,ora ccnifcam of RIiCIi1PT#
orkers Compcnsmion lnsurantt oracenified copy Nercof(Se<.3800,Lab C.)which - PARK FEE YN
- ccs all employee's undenhia permit _ - NC.a OVILETS [CE
Poliryp BUILD G ISS
N PEfig
CcmPany GAS-EA.SYSITjMOVHR4GEU PLANCHECKF
❑ CenifieJcopyisheeebyfurished.
❑ CcnitleJ urpy is flet with the city inspemian division. GRHASMNDUSTRL WASTE INTERCEPTOR GRADING FF
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS
COMPENSATION INSURANCE
This section ncednnt hernmpletudirlhepennit lsforonohandraldollara($IOU) SEWER-SANITARY-STORM FA.200T. BNER ?P
or less.)
I certify ohm in the peefnrmanee of the work for which this permit is issued,I shall
not employ my person in any manner so as to become subject to the Workers' PAID
COmpersall,,n Lawsof Califomis. Date WATER SYS'IEM/1'RHA'I'1NG Date Receipt#
Q z Applicant
z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. SLIs" rs� TOTAL:
(q became subject to the Worker's Compensation provisions of the Lmor Code,you mast
foMwith comply with such provisions or this permit shall be,deemed revoked. p SEISMIC FEE BUILDING FEE
W G #
a Q CONSTRUCTION LENDING AGENCY
Z
Iy affirm that rheic is ng a
construction lendingency for the perfnmmunce of
Uwork
O the forfur
wM1icM1 this permit is (Sec.3rd].Civ.CJ TOTAL: ELECTRIC FEE O f+
Ls Lender's Name PLUMBING FEE 2 s/
F Leader'a Addrea QTY. MECHANICAL PERMIT FEE
U I ccnify that 1 have read this application and state that the above information is MECHANICAL FEE
LU correct:I agree to comply with all city and county ordinances and Stam laws relating to PERMIT ISSUANCE �rOd
F" Cie) buildingeanstruction,and hereby aurhorim representatives of this city toemer upon the CONSTRUCTION TAX
U Z .Mane-mentioned property for inapeaion purposes. ALTER OR ADD TO MSCI I.
(W<)agree w save,indemnify .riclose
keep hwmless the City of Cupertino against
Iiabiliries,ju moms.costs and exp s whichmay in any way accrvc against said City AIR HANDLING UNIT fTO IO.OW CFM)
e,,r ore gaming nn ' Karma.
-?-/-47 AIR HANDLING UNIT(OVER 10,000 CFM)
i%n ofA ml mint Dote El(HAUST IIOOD(W/DUCT)
PAID
R MATERIALS DISCLOSURE
HEATING UNI'F(TO 100,000BTU) Date Receipt# per%
Will the applicant or future building occupant store or handle hazardous material TOTAL: p /2
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00.000 BTU)
Code,Section 25532(.)? Y(SINGE ,t7
❑Yes ❑No
ISSUANCE DATLO l/
Will lheapplicum orfmurebuil0ingoecupwn umequipmentoNevlceswhich emit BOILP,R-COMP PITT OR 100,000 BTU1 / 7
j"wa ani.comandnanw es defined by the Bay Asa Ab QualityManagesnent BOILER-COMP(OVER 100,000 BTU) Ali
^ Q
n
13 Yea
11 No NEW RESIDENTIAL MECH. SQ.FT. a /
I have rtad he haurdous rancrinls requirements ander Chapter 6.95 of the MAR 1 1995
'Califomla Health&Safety Code Sections 25505,25533 and 25534. 1 understand than
d the building Jces nut currently have a tenant,that titan,responxibillly to notify the
«cupanl of Ne reyuiremen¢which must be met prior to issuance of a Cenificme or
Occupancy.
CN Y yr wTetfIINU
Owner or authorized agent Date TOTAL: q ISSUED BY:
OFFICE