27450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILIN -M ELECTRICAL PERMIT NO. 0
CAL
BUILDING DIVISION APPLICATION/PERMIT PLUMPINGROJECTEDENTIFIC
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
IUNIT# LOT#
OWSIERS# PIIONE: A 'SN CN
NIC CONTROL#
RCHITE LIC NO: ADf� ,y-, E]CONTACT: PHONE: `
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT IN
BLDG ELECT PLUM MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL )�CRIMION
p00 Ihcrebyaf0rmthssl amlicenaed nderproProfessions
C.M9(commencing with
ta100 Section]0(q)of DivisianJof the iness and Rofasiona Code,yid my license is in PANELS
X UC fall lose an ,V
FZu1 Licrne C� Lic.N O UPT0200AMPS
N y De¢ Convecwr 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
y
ZO � OVER 1000 AMPS
ARCHITECTS DECLARATION
O Z to O I understand my plans.hall be tared n public records.
,Cy zm SIGNS ELECTRICAL
Licensed Professional
K OWNER-BUILDER DECLARATION SPECIAL CIRCUR/M
5°5d'O F 1 hereby affirm shat 1 am exempt from the Cmmr,ors License Law for the
rU'3 pm following mason.(Semon 7031.5,Business and Professions Code:Any city or county TEMP.METE POIE,,INST.
rn which acclaim a permit w comvuct.alcor,improve,demolish,m mpair any atmmtam
pd.,to its isomme,alsoroS.ion Ncapplicatn formch .I,nor III...gaedesammem PO E VICES
OOm
that he is licensed pursuant to the provisions of the Contractors License Law(C_..
c' eLL 9(commencing with Section 70Wlaf Division Business and Professions Code) SWIMMING POOL ELECTRIC / ATION
UYj_y ar thss he ie exempuherefrom vtd the basis for Ne alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �4(/
Z< Section]031.5 by arty epPI Mtlorapermitsubjectstheapplicanrmacivilpenaltyof
❑
no,more In.f.cr fthedodny,ormSSW). NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ ous,wrk.anhepropengor som intoyearewiNwagnu Neirso.7044. Usines,
will dothewons Code: he Conttructureractor
is License La do not
to an Baseness
aro Professions Code:The Centnmon, nd whe Lew docs not apply lf rt owner of
property who builds or improves thereon,end who don such work Nmselfor through his
employecx,proviJW thatxuch improvementaamnosimm�ded orof(ered Tarsale.
If. OCC.GROUP RES,UNITS
however,the building or impmvetmem is said within one year ofcomplesion,she owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ Lnownerohhe property,emexdusively convecting with licensed romrxtors to QTY. PLUMBING PERMIT FEEI1.00D ZONE MN
constmct the project(Sec.7W,Business and Padeeasions Code:)The Conttacwix
License Lawdoessum apply manownerofpmpcny whobuildsor impro.esthemon,and PERMIT ISSUANCE
whoconaracts forsuch projects with acontnctor(s)licensed pursuant to the Contrechms ALTER EA
License Law. ( ) FEE SUMMARY
❑ 1 em exempt under Sec. B&P C for Nie reason BACK FLOW PROTECT.DEVICE ouT.ID-
FEET—
SANITARY Y N
I� Owner Dam RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TA Y N
$—H rehy af0mslhatl have.cmificem of consemmself-insure,are mnificme of FIXTURES-MRTRAP RP.CF.II'1'N
Worken'Compensarion lnsurencear �enified copy Nereof(Sec.38W,Lab CJwhlch PARK FEY N
sell et w0lathiygmait. GAS-EA.SYSTEM-1 INC.4 OUTLETS R IPO#
Polity# r `/ �Yd//lC5 BUILDING DI SIO#FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PI. CHECK FEE
❑ GenlfiWC y is herebyfumished.
❑ CenifiW copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR DING FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
COussemion need not be completed ifthe permit is foronehondrad dollars(1100) SEWER-SANITARY-STORM EA.200FT. ENERGYI
orins.)
I certify that in the performance of the work for which this permit i6 issued,l shat) WATER HEATER WNENTI?LECIR
nm employ any person in any manner so as to hcome object to the Workers' 1
Compensation liw.of Califomiu. Date WATER SYSTEM/TREATING at R tN-
O Z Applicant
z NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL FILMS. SQ,FT. L TOTAL:
E-i In become subject to the Workers Compensation provisions of the Lalwr Code.you must
Fri j forthwith comply with such provisions or this permit shall be deemed revoked. BUILUNGME
CONSTRUCTION LENDING AGENCY
W Q SEISMIC FEE
J z w 1 herby a ties there is conewmion lending agency for the perfoamantt of
the work for whichtch this permit is i (Sec.ssued(S .309],Co.C.) TOTAL: ELECfRI E
L) O Lender's Narm
U. E-' Lender's Address QTY, MECHANICAL PERMIT FEE mixTBING FEE
O U I certify Net 1 have read this application and atom that Ne above information is MECHANICAL FEE
I--'t: 0L correct.l agree so comply with all city and county ordinances and slate laws missing to PERMIT ISSUANCE
rAbuilding conavuetian.and hereby amhoriu representatives ofthiscity meaner upon she CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep harNess the City of Cantons,against
Imbilitierjudgments,costs and expenses which may in any way accme ag.insssaid City AIR HANDLING UNIT(TO 10,000 CFM)
in conecluence of she granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicarr Convactor Dam EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100 TU) Data Receipt N
Will the the tinin CpeoroMubuildingde,Caper rem hadadd
hazardousmaterial HFATING UNIT R1WAW BTU) TO AU
m dc0ned by the Cupertino Mum d Calc,Chapin 9.12,and the Health and Safety
Code,Section 25532(.)? VENILA FAN(SINGLE RESID)
13 Yea
ISSUANCLDATE
WilltheapplimlorNwrtbuildingmcupensuseecluipment or devices which emit I . -COMP(3HPOR100,000BTU) p
hanNous ah comaminants as d coed by the Bay Arm Air Quality Management Oil FR-COMP(OVER 100,000 BTU) W
Distinct? 9 0
❑Yes ❑ NEW RESIDENTIAL MECH. SQ.FT. /�
1 have read the lg
axardaus meriels sequiremenu undo Chapter 6.95 of the
CelifomiaHmlth&Safety Cod Sections 25505,35533 ond255M. l understand Net
ifthe building does not em have amnm, l it is mymponsibility to notify the
tzcupvnt of t e aeyuir m h ust be et r to issuance of a Certificate of
Occupanc l
Own a ria Date TOTAL: ISSUEDB .
OFFICE