27932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL ;N i-ELECTNICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT IDENTICAL 27932
BUILDING PROJECT'IUEN'TINICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSSUURNETALDATE
q2Z- LIBE[2T CT. UNIT# LOT#
OWNERS NAME: PHONE: CONTN R'SN LIC NO: NIC CONTROLk
ALAI] Yv t4o8)LIC 83 ❑
RCUITtiC1'/ENGINEF.R: LIC NO: ADDRESS:
ID i� c213 r6
.NIACIN: PHONE.: BUILDIN PERMIT INFO
�1'�� '[�'j]a,L� C4�� fi / QTY, ELECTRIC PERMIT FTie
i�U I� I �r-'-�`"I _3: PERMIT ISSUANCFi BLDG E UM MECH
LICENSED CONTRALTO ' ECLARATT APPLIANCES-RESIDENTIAL J DESCRIPI'1 N
p tyZ IhercM1y afftm tvtlem licensed and rovisionsofChapter.(commencing with
ts1 O Section force and)of Uivisinn J of Ne Bu' ss end Pmfeasiom Code, d my licrnse is in PANELS
L'V fullse Cladeffect. II�/]
pQ„Z License Class Lic.If UPT02MAMN
mQy Dae Convector 201-1000 AMPS
Z8y2� ARCHITECTS DECLARATION OVER IOW AMPS SQ.ET,FL�OI�ARFA arsQ.Fr.
I understand my plan shell be used as public records.
KNE SIGNS ELEC RICAL WJ
4q '—.4 Licen Pural.ional
Lzo�'Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaU 1 ercby affirm that 1 um exempt from the Contractors Lice se law for the
W 3 u.h follow ng rcmon.(Section 7031.5.Business and Professions Code:A y city or county TEMP.METER OR POLE INST.
1��'oyJ whichissuan
yuires a pemtit m enns1.0,after,improve demolish,or rc r tiny structure O
yW poo itstt,alsorrymrestintit"ie tforuch nnutoflea igned semumu POWER DEVICES paa�
Iy LL�p thah islim.sed,mxmnnothep viol C a ' imn Law(Chapter SWIMMING POOL ELECTRIC
n.$a.o�' Sled cingwit Section7000)o ajl.,messand fissions Code) ATION
,^y or that a iemeopnh from dth alleged exemp' nyviolaiono VfLEI'S-SWITCHES-FIXTTJRES r
�ZQ Sectio T(131.Sb an plc if a tsubjects the app l' notoo ivil penalty of
� p
.... thanf, a W).
s
El 1. saw Graf ormy employees with gcaustheirsole mpensation, NEWRFSIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCI'ION
ywill cwork,mdthe tract isnotinteadeclar ctel orsale(Sce.] ,Business
and Pro sximi,Cade: e C tractors Lia law dos not apply m a.owner of
progeny hahuildsmim ex thereon, hodoessucbwmkhimselfmIhroughhiaOCC.GROUP NES.UNITS
ownempl mo,providedtetsochim mentaerenotimendedoroffeta forsele.IL
however,t buildingmimprove is sold withinone yeurofcompletion,theowner-
builder will ave the burden o ving that he did not build or improve for purpme of
4e 1.4
ns
owac oft perry,am exclusively contracting wit licensed contractors to QTY, PLUMBING PERMIT FEE FLOOD ZONE UNITS
as
cothe prr ml(Sect 7044,Business and Prefeasions Cale:)The Cmlractars
License law does not apply loan ownerofpropen,who builds or improves therein,and PERMIT ISSUANCE
whoemormts forsuch projects with a convactorts)licensed pursuant mhe Contractors
License Law. ALTER-DRAIN @ VENT-WATER(EAJ PEE SUMMARY
❑ 1 am exempt ands Sec. B @ P C for tie reason IIT.
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
[I Ihereby.ffirmthalcwcaccnificmeof canoe...selM1insme.maa.ificateof FIXTURES-P TRAP RECEIPT#
Workers'Com,nartion Insurance or a terrified copy thereof(Sec.380y,Lab C.)which PARK FEE Y N
coverasllempl.yce''sundertia,mon. GAS-EA. STEM- NC.4OUTLETS RECEIPT#
Policy# BUILDING DIVISION EE
Company GAS- SYSTEM-OVE (EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ CenifieJ copy is fled with Ne city inspection Jivisinn. GRP SFJINDUSTRL WASTE I RCEPTOR GRADING FEE �.
CERTIFICATE OF EXEMPTION FROM WORKERS' CASETRAP SOILS FEE
COMPENSATION INSURANCE
rlc(This section need not he completed lithe permit is fortune hundreddollan(I HE) SEWER-SANITA Y- EA.2W . ENERGY FEC `
I certifythat in the performance ofthe work for which tis pmiu isiscai Ish< WATER HEA
not employ any person in any manner an as to become subject m the Werke.' PAID
Compensation Lvwsof California. Date WAqFltSjTEWR^1N0yDate Receipt art
Q Z Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NE ID. PLM SQ.IT. TOTAL:
(n become subject o the Workers Comperwtion Provisions ofthe labor Code,you most
fnnhv di comply with such provisions or this Permit shell be deemedece.ked. BUILDING FE a /d
W z CO NSTRUCf10Nction GAGENCY SEISMIC FEE
2.
?O
5 I hcrehy hick t is that is i sued(Sm.3 lending agency for the performance of ��
the work for which this permit is issued(Sm.3097,Civ.CJ ELECTRIC FEE
OO lender's Name v PLUMBING FEE
[V� Lender's Address QTY. M IIANICAL PERMIT FEE
I certify that 1 have read this upplication and state that the above information is MECHANICAL.FEE
�^ correct.lagree to comply with all city and countyordoones and....cliws.I.B.gto PERMIT ISSUANCE
tiIn building construction,and hereby anthodx repumematives ofthiscity toenter upon the CONSTRUCTION TAX
V 7-. above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree or save,indemnify and keep handle.to City of Capmiao egrinst
liabilities,' mints,costs undexpcnus whichmvy in anyway accrue against said City AIR HANDLING UNIT(TO 10,00(1 CFM)
I.con . fthegrantingof0u.Nmit.
t s-18'qsz AIR HANDLING UNIT(OVER 10,000 CFM)
Si aura. PP .mottoDate EXHAUST HOOD(W/DU(7O
PAID
HAZARDOUS MATERIALS SURE HEATING UNIT(TO IW,WB BTU) Date Receipt#
Will the applicant an Boum building occupant storem handle h neadous mmedal HEATING UNIT(OVER 1 W,IgO BTU) TOTAL:
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Sect253J2(ep
CI Yes 11 No
VENTILATION FAN(SINGLE RFSID) Q
❑
" - ISSUANCE DATE
Will theapplicantofuture mildingmer,mt useeyuipment.rdevices whichemit BOILER-COME JHP OR 100,000 BTU) tI�(� N
hamrdous air romaman
inta m defined by to Bay Are.Air Qualify Manvgemem BOILER-COME(OVER 100,000 BTU) WAY 17 1995
District]
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT.
CITY Ur WrtnuNU
I have mad to Safety
n e,mateo s 5505.25533 under Chapter understood
of the
if Calthe
buil Health@ Safety Code,Sections25505,t it is and 23534.1undcnotif[hat
ifthebuildinge renot
mentscurrently have ast be, tato is mysuanceofa enotify to
occupant of the requirements which must be met prior to issuance of a Ccnificam of
tXcapaney.
Uwner or authodu0.gem Orae ISSUEOR .
OFFICE