27797 J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11101"°ING-RLECrIUMAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 27797
BUILDING PROJECT IDEN'1
AT
'IFIC10N
BUILDING
ADDR !\ I SANITARY NO. APPLICATIIOONa•SSUUBMMAL DATE
�V/ JEi9k}7ol�DR UNIT# ` 1.01 \ �\v\ (kJ
OWNI±RS NAMR: PHONE: COM' ACfO 'S NAME LIC NO: NIC CONTROLp
,wrw u JT d �/✓ eJ d
SRCHOI DC`T/FNGINEER: CNO: RFS
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
,@LDG
ELECT PLUMB MOH
p N1 a Y�g ) G S PERMR ISSUANCE �{{JB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB ON
pyrZ Ihcrebyaf Di that antlic-Basin ,add onfiesns of s Code,and
mmencing If.with _II`"l//` x/V�Jy\\WW"txDESCRIPTION
Ax'rr�s'--JJR' 1' �__I 1(_'Y-1�]�—` .{lr-,cr
�ilOp Sectiarceandef Divisionlofthe Business end Profesiona Code,and myliceau is in PANELS
yv�+IF full fineeend-lfeet. 11
6F Z ty Dstcrmc Class Lic# UP TO 200 AMPS
w Q y Dam Contmnor 201-1000 AMPS
ZO or,z ARCHITECTS DECLARATION OVER I000AMP5 SQ.FT.FLOORAREA $/SQ,FT,
OZ-0 I understand my plans shell be used os public recons.
�yID SIGNS ELECTRICAL
licensed Profeaainnul
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
a'OyF I hereby affirm that 1 am exempt from the Conumors Lima.Law fm the
B1'3Qm following mom.(Sontim 7031.5.Business and Professions Cade:Any city or county TEMP.MEIERORPOIEINST.
Icy; which requires a permit to constrict,alter,improve,demolish,or repair any structure
a2 prior o its issuance,also requires the applicant for such permit to file a signed matement POWER DEVICES
y) p her he is licensed pursuant in the provisions of be Commcar's License Lew(Chapter
d6o0� 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violations( OUTLETS-SWITCHES-FlXTURE$
ZQ Se[tion70315 by any appli[aa fora pmmltsubjeds the applicant a civil Penalty of
t more than five hundred ddllna(E500).
M'_� ❑ I,eow croftheprop ny,ormyemploy ewiNwegesstheirmlecomp oeGNEW RESIDENTIAL ELECTR on, —5 Q.FT. STORIES TYPE CONS RUCTON
will do he wort the snucture isnot inrtnd-dmabfered fmade(Sm.]044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
prnpcnywhobuildsarimpmves thereon,and whodoessuch work himacror through his
wnemployeex.provided that such improvemeasaredm lmendedoroffcrcd burials,If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yen of completion,the owner
builder will have the burden of that he did not build or int TOTAL:
proving prove for purpose of
safe.).
❑ I,es owners!the prupeny,nmexdueivdycontrnctingwithlicenuJ dmvactorsm QTY. PLUMBING PERMIT FEE FLOOD ONE APN
canstmct the project(Sm.70,14.Business and Profesions Code:)The Contractors
License Lewdness notapply men ownerof,in coy who builds or improve thermn,and ITISSUANCE
whocontmcts for such prajmts with acoarectuds)licensed pursuantto the Contractor's
Liocnsc Law. ALTER-D IN&VENT-WATER MA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this res OUT ID. ' ES
BACK FLOW PR CT.DEVICE SANITARY Y N
Owner Data RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOG ,ROOF, ,COND. SCHOOL TAX YN
❑ Therebyuffinnthmlhuveucenifi[meofeonsennoself-insure.ora ificme of RECEIPT#
FIXTUR -PER AP
mkers'Compensetion lnvumnce oracmiOeJ copy thereof(Sm.3NI. bCJ which PARK FEE Y N
mvenallemployeasunderthispemmil GAS-EAS C.40UTLETS - RECF.IPI'#
Policy# BUILDW G DIVISION FEES
Company GAA. TEM-OVER4 PLANCHECK FEC
❑ Cenified c.,is hemby famished.
❑ Cmifird mpy is filed with the city inspection division. GWSFJNDUSTAS I RCS
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORK"" AP
COMPENSATION INSURANCE SOILS FEE
(Thus section need not be completed ifthe permit is for one hundr dollare($100) SEWER-SA 1'TARY-ST EA.2WFT. ENL'RGY FEE
or les.)
I certify Nat in the performance ofthe work for which this permit issued,l shall WATER HEATER W 'N/ELECIR
not employ any parson in any manner ao as to became subject tt1y11 =CU`1-
U
PAID
Compensaticalswsob Califamia. Dam WATER SYST EATING Date Receipt#
Z Applicant
Z 0 NOTICE TO APPLICANT:If,afterm�ing this Cenificateof Excmpti NEW R ENTNL PLMB. SQ.FT. TOTAL:
p+ � become subject to the Workers Com,mosatim provisions of the Lebar> fohwith comply with such provisions or this permit shall be decmed BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
VZ I hereby affirm that then is a construction lending agency for the perfonnence ofTOTAL: ELECTRIC FEG
O the work for which this permit is issued(Sm.309],Civ.CJLaI,cndeex NamcPLUMBING PEE
L<ndcrs Address QTY. MECHANICAL PERMIT FEE I, I Net I havcomply
rind this city
md application and rote that an above ws land,is
V) cored logrcemcn,and with.11 yauthaad coumynNtives awns soda tentermingm PERMIT ISSUANCE MECHANICAL FEE
.FrZ ahwangmnswdiro,mdhcrchyueNmi purposes,
uvea of thiscitymercer ulnmhe CONSIRUCTEONTAX
C) z aMv Wi ogre,property flur ndemnifyand Jump us. ALTER ORADD TOMECIi.
(We)agrecasave,sadd a.11, and kap harm less the City of Cupenst said
Citt
liabilitie.judgn Is,costa ander swhich may in any way mmrmengalmtaaid Ciry AIR HANDLING UNIT(TO 10,000 CFM)
in conommc a anting t kkm
AIR HANDLING UNIT(OVER 10.000CFM)
Sign um V11RODUS
Our Des EXHAUSTHOOD(WMUC)
PAID
n,bMATERIALSDISCLOSUREHEATING UNIT(TO100,000 BTU) Dam Rmeipt#
Will theompid C de,C am pure or handle hHealth s mmttidl
e defined byunicipal Code,Chapter 9.12,end the Health and Safely HEATING UNIT(OVER 100.00)BTU) T
Cede,Section❑Yea ID
❑No VENTILATION PAN(SINGLE RMID) Fj
ISSUA�ACIIE#���DATE
Will thea tic torfmurc huildin occupanmucyui BOILER-COMP(3HP OR 100,000 BTU) ^R
pp B pmrntordeviceswhichemit
m ms air commandants a defined by the Bay Area Air Qmlity Management BOILER-COW(OVER 100,"BTU) 419 5
'strict? n
❑Yes ❑No NEW RESLDCNTIAL MECH. SQ.FT. CII I VT, 9
1 have read the hasurdous materials requirements under Chapter 6.95 of the VVC�
ifteulinHealtho&of cty Cade.Sections 255115,25533 and 25534. I understand that
California the building Anes not Solely
currentlyCode have n n nam,that it is my responsibility a notify the
Occupant of the rtyuiremems which must be met prior w issuance of n Cenifems of
rx[apm[y.
Ownerornmhonudngem Data TOTAL: ISSUED BY:
OFFICE