27660 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
4ARCHN
UFERTINO H ILDI G-ELE '1'0.1 AI. PERMITNO.
APPLICATION/PERMIT I'INGPRFr,-MEDENTIFICL n 7 6 6 O
BUILDING DIVISION BI111.IPLUMBIN ECT MECHANICAL
L fJ v
ESS: SANITARY NO. APPLICATION SUBMITTAL DATE
" r
UNIT# LOT Is
' F 1111 NE: CONTRACTOR'SNAMI?: LIC NO: N/C 4 CONTROL#
0I 1?I?R: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT I UMIJ, ,MECH
PERMIT ISSUANCI?
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R17 IDEITIAL
QWz lberebyaffnn Orad um licemudinderprovfirms of Chapmo9(commencing with
0p ty+ Section ofDivision 3nf the Business and Professions Coda and my license is in PANELS V Uq full forcerceaddand effect.
<Fzty Licenu Class Le.# UP T02W AMPS
N=y Date Contracmr 201-Iq9 AMPS
zOyz ARCHITF.CTSDECLARATION SQ.FT.FLOOR AREA $/SQ.IT.
OVER IW AMPS
0z—IO I understand my plans shell be used m public records.
Pr25 SIGNS ELECTRICAL
�jYY •� Licensed Professional
G yvbe< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O c, I hereby affirm that I um exempt from the Cordovan's License Law for the
tn following mason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�50< which requires a permit to contract,alter,improve,demolish,or repair any structure
��Y� to its issuance,tobnon aims thea liter foravch uo filen si bostatement POWER DEVICES
prior tt pp .it gn
W C C O that he is licensed pursuant m the provisions of the Contractor's License Lew IChapmr
14a�0�' 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL HLECIRIC gL'1.Tt�
W_y
."but he is exempt therefrom and me foods far the alleged exemption.Any violation of rr^J
Lzi< Section 7031.5 by any app amfor a Permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES \
1,+aj not morethan five hundred dollars($50(r). NEW RMIDEMDAL HLECT _ Q,FT.
RS
❑ I,uwtwnernOhc pnalreny,nrmyemployeee with wngewstbcirsolecompensotinn, TOR TYPE CONSTRUCTION
awllldolhewnfk.and,lov,rutiou is anintended orofeocd hostile(See,7044,Business \
and Professions Cade:11x,Contractor's Licenu l.aw retention apply to an owner of
propcny whobuilds orimpnrves thereon.and whodoesxucM1 work bimselfortNough hie OCC.GR RES.UNITS
w�e this es,p ing.,i improvement
withinne ear.froolled.d themle.IL
bowevn,ilm have
the burden
ofp nsm is sold within one year ofcoparove for
owner- TOTAL:
Wilder will hove m<Burden of proving that he did nm build or imlmme for puryose of
le.).
❑ I,as ownerofthepured ,eescWsivelycuntracting with licroscdncotmre eroto QTY. PLUMBING PERMIT FEE ROOD ZONE
m APN
construct the project(Sec.1(44,Business end Professions Cale:)The Cargo 'sPERMIT ISSUANCE
Low dors not apply loan ownerofproen
py whobuidim improves thereon,and
.hoc rhoursf..mehpmjcete whhn c.t,r.teg,)Ileettud purswmt mthe Contractor's gLTHR-DRAIN&VENT-WA'I?R(PA)
License Law. FEE SUMMARY
❑ 1 nm exrntpt under Scc. ,B&P C(or this reason BACK FLOW PROTECT.DEVICE
SANITARY Y D N
Owner Data - RECFITp
WORKMAN COMPENSATION DECLARATION DRAINS-ROOR,ROOF,AREA,COND. SCHOOLTAX Y N
0 covers❑ thereby Nfirmthm lhaveacenificate ofconxmto self-insure,oraartificam a( RECEIPT#
FlXTI3RES-PER TRAP
Wnrkeri Compensation Insurance oracertificd ropy thereof l$ec.38W,Lab CJ which PARK FEE YN
all employee's under this permit. GAS-EA.SYST[Bvri INC.4 OUTLETS RHCEIPT p
Policy# BUILDING DIVISION FEES
C..ommy GAS-EA.SYSITM-0VER4(EA) PLANCHECK FEE t
❑ Cmified copy is hereby fun oolmd.'
❑ CeniliW copy is fled with the city inspenian division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP SOILS FEE
COMPENSATION WSURANC13
(This scrtionaenlnot be completed Bloc permit is future hundraidolless($IW) SEWER-SANITARY-STORM G.200F`L FNERGY FEE
or leas.)
I certify that in the performance ofthe work for which this pandit is issued,l shall W ;R W/VENT/ELECI'R
not employ any person in any n o as m become subject to the Worked' PAID
Z Cnmpanxatinn Luws of California aDam s WATERSYST /BEATING Dam Receipt#
applicant
z� 0 N01 ICE TO APPLICANT1':If,after making this Ceniftcate of Exemption,you should . IDI?NTIALPI.MB. SQ.FT. 'TOTAL:
!—t fp became subject o the Worker's Compensation provisions ofthe Labor Code,you must
F� 7 fnnhwith comply with such provisions or this pmnit shell be deemed revoked. BUILDINOFEE
yQ CONSTRUCION LENDING AGENCY SEISMIC
I hereby afford that is u construction lending agency for the performance of T H'A ELECTRIC U O the work for which this permit is issued(Sec.3091,Civ.C.)I.1orrI sNamaPLUMBI0 U IcndersAddress Q'I'Y, MECIIANICALPERMIT FEEI certify mm I have read this application and nate mut the above information iecorrect.I agree m comply with all city and county ordinances and state laws reladogto PERMIT ISSUANCE MECHAN� building conswction,and hereby authoriurepreumatives of thisciry lumberman theCONSTR
U z above- onion rompanyfirmspectionpurpoces. ALTER OR ADD TO MECH.
( aa are o inJ id .1 a Cit of Cupertino against
liabilities,' gree esprnses or -comagalnst said City AIR I IANDLING UNIT(TO 10,000 CFM)
juristic it, f mg of th's
910. IN HANDLING UNIT(OVER 10,0011 CFM)
i
S' licnn `ummc r Date EXHAUST000D(W/DUC)
PNU
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,WO BTU) Data Receipt
Willmeapplicant or future building occupant smrcm handle hazmdous mamdal HEATING UNIT(OVER 100,000 BTU) TOTAL:
m defined by the Cupertino Municipal Cade,Chapter 9.12,and me Health and Safety
Cade,Section 25532(x)'! VENTILATION FAN(SINGLE RESID) �I
❑Yes El No
-17
Will the applicamorfmurebuildiagoccup rmuse equiptrmmordeviceswhich emit
BOILER-COMP(.)IIP OR I W,000 BTU) ISSUANCE DATE.
• hazardous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 1110,0(10 BTU)
Dietdet" - 'P A '1
❑Yes ❑No NEW RESIDFN'1'IAL MGCH. SQ.FI'.
1 have reed the huurdous mamdod,requirements under Chapter 6.95 of the NOV 2 8 199
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
ifthebuilding does not currently have a tenant, itis my responsibility to notify me V
occupantan C
of the requirements which nun be not
prior to issuance are Cenifica¢of
Occupancy.Occupancy. V Uf f;f)Mt-lye„rte
Owner or authorised agent Dote TOTAL: ISSUED BY:
OFFICE