27798 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EE RACAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL N� pp
BUILDING PROJECTIDEN'I'[FICA'I'[ON G J O
BUILDING ADDRESS: do SANITARY NO. APPLICATION SUBMITTAL DATE
�7M1 �� UNIT LOT#
O NIiR$NA !: PHONE: CO '1'RA{q'Qy:CN MA E: _�� LIC NO:
o �SiN T J „�-_Nw/7� NIC CONTROL Of
RCIIITECT/ENGINF.ER: L NO: �/ ❑
CONTACT: PHONE: �,J BUILDING PERMIT INFO
�f//�/Ji QTY, ELECTRIC PERMIT FEEJa/ • • v 0����/ �f�a PERMIT ISSUANCE BLDG ELECT PLUMB MECH
�4 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
n=Z I hereby affirmthat l am licensed underpmvisionsofChapter9(commencing with
ts100 Section]000)of Diision 3 ofthe Businessand Professions Colk,and my license is in PANELS
�ul full farce and effm�
I;,Zu1 License Class LIC.# r�9' 4S'3 UP T021NIAMPS
m GG=y Date Comncmr 201-IIXp AMPS
'LO,,,z' ARCHITECT'S DECLARATION OVER 10011AMPS SQ.FT.FLOOR AREA E/SQ.FT.
O Z—❑ I underswnd my plea,shell he,used a,public records.
G SIGNS ELECTRICAL
aY Licensed Pr.fessinnel
N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
K�
5,0
�aaxyF I hereby affirm that 1 am exempt from the Contrmrors License Law for the
W 3 tt y following rcasng.(Section]031.5.Business and Profeaei.ns Cade:Any city or county TEMP.MPTER OR POLE INST.
F-(+t�� which requir a permit to construct,alter,improve,dental ish,or repair any.1ommre
>7 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W�N<0 that he is licensed pursuant to the provisions of the Communes License Law(Chapter
e. 9(commencing with Second 70(smof Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
.,that he excmpnherefrom and the basis for alleged exemption.Any violation of OUTLETS Section 9031.5 by any applicant for a permit subjects the applicantto o civil penalty of FIXTURES
m mom than five hundred dollars($500).
04 ❑ I,asownerofthe n yemp y gesastheirsolecompensation, NEW RESIDENTIAL ELECDR _SQ.FT.
43e_ props y,orm erred.,Ofere STORIES TYPE CONSTRICTION
—e will Jnthe,icn,and the stye cture Cocisnotimeicese L..Offor fered e(Seeapply a, ao wins
and Professions Cade:The improves
tho ars License Low docs or apply lf am owner is
prop ertywhobuildsviimprovesthereon,endwho does such work oroffiforthrough his
own employees,
lding Or imprsuchimpmvemeitsarene ear ofdoroffern,hostile. r- OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ,completion,the owner- TOTAL:
salWer will have the burden.(proving that he did not build or improve for puspnxe of
alt.).
❑ I,asowncrofthepropeny.amexdusively comrmting wiN licensed contsecmnm QTY. PLUMBING RMIT FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions Cale:)The Contractors
License Law does not apply Ina,ownerofproperry who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a coutwor(s)licensed pursuant to the Commdore ALTER-DRAIN& NT-WATIiN LA
License Law. (s ) FEE SUMMARY
El 1 am exempt under Sm. ,B&P C far this reason BACK ROW P TELT.DEVICE. OUT.IDE FEES
SANITARY Y N
Owner Date DRAINS �.00R,ROOK AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
Humbyafftrde Nat lheveaceniftcateofcwwnitoself-insum,orammlicateof RFS-PER TRAP RECEIPTp
rnkers'Compcnmtion Insurance m iseeni6ed copy@creof(Sce.3800,Lab C.)which PARK FEE Y N
cmers all employee's under this permit GAS-EA.SYSTEM.IINC.4 '.TS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER
C3 Certified copy is hereby famished. 1 PLANCHHCK FEE
❑ Certified ropy is filed with the city interaction division. GRFASE4 U I . C
GRADING ALE
CHRTIFICAI'17 OF FMMPTION FROM WORKERSGREASE'I'RA %. SOILS PEG
COMPENSATION INSURANCE
(This smliun need nut becampleted ifthe permit is(.,arm hundred dollars 0$100) SEWER-SANITAR ORM EA.200FT. ENERGY FEE
or less.)
I certify lhat m meperfonricme.f Oa work for which thispermit is issued,l shall WATER PRATER WNENT/ELECfR
mut employ any person in any manner ns as to hecome subject to the Workers' PAID
z Compensation laws of Califomis. Date TER SYSTEM/BEA77NG Date Receipt p
Applicant
z NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you should NF. FSIDIIIAL PLMB. SQ,FT. TOTAL:
n f/] become subjccno the Worker's Compensation provisions of the Lnbnr Code,you must
C4> forthwith comply with such provisions or this permit shell be deemed revoked. BUILDING PER
Uj Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this pc.it is issued(Sm.3097,Civ.CJ
Landers Name
Lender's Address QTY. MECHANICAL PERMIT PEE PLUMBING ME
1 certify that I have real this application end statethatthe above information is
S buirect. I agree to construction,
it hereby th all cglatrity county ordinances and stem kwsrtipors to PL•RMIT ISSUANCE MECHANICAL FEE
buildingcotioned ropers hercbypectioizereoses.moves of thiscitymenter uponthe CONSTRUCTION TAX
V above-mentioned property for inspection purposes. ALTER OR ADD TO MF.CH.
(We)agree to save,indemnify and r hanNess the City of Cupertino against
labiluie•fJ Ignsents,costs rnlel�penses which may in anyway acerueagainst said City AIR HANDLING UNIT(TO 10,0110 CFM)
in co qtr ce egmmin (Nis Pemtit.
AIR HANDLING UNIT(OVER 10,"CFM)
umry p an o rector Date EXHAUST HOOD(W/pUC13
PAID
HAZARDOUS MA'ITRIALS DISCLOSURE HEATINGUNIT(TO 100,"ITTU) Date Receipt Or
Wil plebe tar forum building mcupant Hurt or handle hnwdous material
as Jefin ythe Cupertino Municipal Cock,Chapter 9.12,and the health and Safety BEATING UNIT(OVER 100,000 BTU) WT44
Cole,Section 0Yes ❑No 23532(a)9
❑ VENTILATION FAN(SINGLE RESID)
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
Willtair conitainant,mor s building by the BayAna Air Quality
Managemench t
R / 0
at
vuim9 11e„
Yes 1:1N. NEW RESIDENTIAL MECH. SQ.FT. 41
1 have mad the hemNom materials requirements under Chapter 6.95 of the 198
California Heald'&Safety Cale,Sections 25505,25533 and 25534. I undefstend that
iflhe handing does not Carmody have a tenant that it is my responsibility to naify the LaC VVs-C
cupand of the requlremems which must be met prior to issuance of a Certificate of
Owacr or and Anrised agent Dote TOTAL: ISSUED BY:
OFFICE