27818 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOI. I -ELM DUCAI. PCRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL A I O aI
BUILDING PROJECT IDENTIFICATION G r o 1
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMIITALDATE
103'41,:- 103S- 1 %A O Q ^CLUNIT# LOTH as
f`
O BIS NAME: �\ PF{ONE: C NTRACII'OR'SNAME: LIC NO: J
olbr VQV� I��YIM �ax ` CQ„ NIC CONTROL#
\ !ITECT/EIJGI`N �O� E 1# IDc.o: ADDRESS:
S .
/" ' A / . ❑ � :3 L�
CONTACT: PHONE:fj
"56)_9 QTY. ELECTRIC PERMIT PBG BUILDING PERMIT INFO
140- n PCRMIT ISSUANCC �D� ELET PLUMB MECI{
�7 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL QWz IherebYaffinth
narlamlittnadl underpmvisiona of CTepta9(cammencingwith JOB DESCRIPTION
POO Secti.r7a")of Divisie�3 ofthe Business and Professions Code,and my license is in PANELS
Kz full force and effect. F�/( �^'7
Ft. License Class Lic.#y �a'r2 �q Z UPT02MAMPS
m G=y Dare Contractor 201-IBM AMPS �•JS PT.FLOOR AREA �w3/S0.0.0.QlllFTvvv11--"'
7OyZ ARCHITECTS DECLARATION OVER UKKI AMPS Q
OZ—FE.�n I understand my plain shall heaved mpublicastrds.
2 y 2 SIGNS ELECTRICAL
s Licensed Professional
yKist< OWNER-BUILDER from
m the Con TION SPECIAL CIRCUIT/MISC.
,gyp(,Oa V I hereby affrrn that 1 oro exempt from the Convacmr's License law for rhe
fallowing rtnson.(Sorban 003 L5.Business end Rm(essionx Code:Any city orroanty TEMP.METER OR POLE INST.
�o, which requires a permit to construct,alter,improve,demolish,or repair any structure
InI2 primmits issuancieslsorsuires theapplarrat formich Permit to fileasignedmitemem POWER DEVICES
W�<0m that h ,t
e is licensed Farmano the provisions of the Contractor's License Low(Chapter
'KOLL 9(commencing with Section7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m(�y orthat he is exempuherefrom end the ba�is(mthe alleged exemption.Any violation of
E-ZQ Satinn 7031.5 by any applicant for a permit subjects the applicants o a civil penalty of OUTLETS.SWITCHES-FIXTURES
iE0�S not more than five hundred dailars(3500). SOPORIES TYPE CONSTRUCTION
❑ I,mownerofthcpmprty.ormyemploymswithwagesutheirsolecompensation, NEWRISIDENTIALELEM _SQ.PT.
y3, willdo the work,and the Shommen isnot inuendedoroffered for sale(Sax.7094,Bushoss
and Professions Code:The Contractor's License Law does not apply to w owner of
property,who buildsorimprovesthercon,andwhodaessuch woh himsnlforthroagh his OCC.GROUP RFS.UNITS
ownemployers,#molded that such improvements are not intended or offend for sole.If,
however,the buildingor improveovent is sold within one yearofcomplcdon,theovorm, TOTAL:
builder,will have the burden of pmvia,that he did not build tar improve for purine of
sale.).
❑ I,as owner mfthe property,sm exclusively contracting with licensed contractors m QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
com or the project(Sm.70 ,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Luw dms not apply to m ow ncr of propeuy who builds or improves thereon,and
who moment(at such projects with acomactiabd licensed Innocent othe Comroctore
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I an exempt under Sec. ,B&P C for this rcasnn BACK FLOW PROTECT.DEVICE GO S -
SANITARY Y_N
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPfieme fONDECLARATION SCHOOLTAX Y N
1 hcrcby afOrm thin I have a certificate a consent er of(Sm.38 o,u ab C.)which
RECEIPT#
-ars Co cnsation lnsurenceareccnifiedcopy thereof(Sm.38M,Lab CJ which PoXTURFS.PER'fRAP PARK FEE Y N
emanRECEIPT#
n elle e'p1n th0z0Lib, GAS-EA.SYSTEM-I INC.40l1Il.F:TS
pal cyp - !� BUILDING DIVAS E
Company GAS.P.A.SYSTEM-OVER ER 4(EA) PLANCIIECK FEF.
❑ Cerifi copy is ere y ..is ed.
❑ Certified copy is filed withthe city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOUS FEE
COMPENSATION INSURANCE
(This section need not has completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STOR .200FT. ENERGY FCC
or Ices.)
I certify that in the perfonnanc of the work for which this permit is banned,l shell WATER HEATS Wry
not employ any person in any manner sass to hccome subject to the Workers'' PAID
Compensamo Lowsof California. Date W TFR Data RemilaN
Z '7" Applicant
O NOTICETOAPPLICANT:ILafmrmold.glhis Cenificamof Exempdon.youaho d J n4kIllSI IA TOTAL:
r~�i becomesuhjea oohs Worksrs Compensotion provisions of the l:nbor Code, ameba t
a .' forthwith comply with such Provisions or this pentdt shall be deemed revok? J BUILDING PEE ,/a
a ;� CONSTRUCTION LENDING AGENCY tl SEISMIC FEE I
1 hereby affirm that there is a construction lending agency for the performs
U O TOTAL: ELECTRIC FEE
Ne work for which this permit is issued(Sec.3097.Civ.CJ
,r Lenders Name
u" t' Lender's Address '1'Y. MECHANICAL PERMIT FEE PLUMBING FEE
LVI.1 1 ce et 1 hon rtaJ this application and state that the above info rk -
Y o :°�° MECHANICAL FEE
P, neat. ogre roman wird all city end county ordinancer and etam Iowa reluungm PERMIT ISSUANCE
V z buildin oast pian,and hcrcby authorize rtprtsentadvesuf thisetymenterupoathe' CONSTRUCTION TAX
above-n nd eJ property for inspection purposes. ALTER OR ADD TO MF-CH.
(W res to save,indemnify and kcep harmless the City of Cupertino against
Ilabilities,j dgments,cosamandexpenuswhich myyyyinanyw sccrueagarearait City AIR HANDLING UNIT(TO 10,"CWl
c seq -Its"iegmni oAcs-
tAilperm 3-Zo�
/C AIR HANDLING UNIT(OVER 10,000 CFM)
Signa ore of APplican innacmr Date E%HAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Raxiptar
Will the applicem or future building occupant=or handle notorious material HEATING UNIT(OVER 100,000 BTU) TOTAL:
m defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Came,Section 255321L)7 VENTILATION FAN(SINGLE RESID)
13 Yet ❑No
001LER-COMP(SHP OR IlkBTU) �,'jSSUAJJ�DATE
Will theapplicenmm
t furebuildingacum
ptuu equipment ordcviccawhichcmit MM 1 u�
hazardous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? MEAIAy�3
❑Yea ❑No NEW RESIDENTIAL CH. SQ.Ff. 19g5
1 have mad the havrdaus materials requirements under Chapter 6.95 of the C//Y UP L JJ
California Health A Safety Code,Sec255
tions 05,25533 end 25534.I understand that Urt
if the building does not currently have a tenant.that it is my responsibility to notify the
occupant of the requirements which mum be,met prim to immam of a Cenifimm of
Occupancy. t
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE