27362 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOM ELECTRICAL 1 A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27362 7 3 6 G
2
BUILDING PROJECT NENTIFICATION G
B LDING ADDRESS:I C,4uvr
^ SANITARY NO. NAP�PLICATION SUBMITTALDATB
22AbWr 3! Q• J I3047 UNITN LOT#
O ERS NAME.: PHONE: CONTRACTOR'S NAME: LIC NO:
VN/C CONTROL#
J✓ /E
ARCHI'IF.CTIE GINEER:ER: LIC NO: DRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �1�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL l�
I hereby ffirm that l am licensed under fate ter9 gwi JOB DESCRIPTION
p0Z ya pmPofeso p andmmenen in
�jbtSection 7000)of Division 3af the Business and l4ufcuiona Cade,end my license is in ppryEpS
FZwF. failucnse Cladeffecv UP TO AMPS
License Class Comm
w 6 vo Ovm Conl.cmr 201-1000 AMPS
Z OyZ ARCHITECT'S DECLARATION OVER Iaf10 AMPS SQ.PT.FLOOR AR S/SQ.FT.
O Z 'I] 1 undemmnd my Plaru shall M used ere public records.
n
RI SIGNS ELECTRICAL
Q� "'1-I Licensed Profeuional
GN�K6 OWNER-BUILDER DECLARATION SPECIAL CIRCUTf/MISC. '
W O cL U 1 hereby affirm that 1 am exempt from the Controversies License Law for Ne
3Cun followin Sation7031.5,Business and Professions Code:An cit oremort TEMP.METER OR PoLE INS?.
g reason.( y y y
f:7�; which tortures a Permit to construct,Wier,improve,demolish,or repair any mouchum -
5,.Y2 prior m its isimence,also requires the applicam forsuch permit to file a signed statement POWER DEVICES
,S:00 that he is licemed p.m.,1.she Provisions of the Connectors License Low(Chapter SWIMMING POOL ELECTRIC
X0� 9(commencingwith Section 70(XDafDivident3ofibeBusiness and PimfessionsCode) VALUATION
W_H or that he is exempt therefrom and the basis(Or the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
LK< Section 7031.5 by any applicant for a Permit subjects the applicant to aeivil penalty
not mthan five hundred dollars($50M. .
Yore NEW RESIDENTIAL CLECtR S FT.Q ❑ hxsowneroOhcpmpeny.ormyemployxswiN wageass theirsolecompensation, Q STORIES TYPE CONSTRUCTION
a3� will do the work,unathe structure isnot intendedoroffered foravle(Sce.7W,Business
and Professions Code:The Commern,License Lew does not apply to an owner of
propcny whobuildsorimprovei thereon,and whodeas such weekhimselforduough his OCC,GROUP RES.UNITS
employees,provided thatsuchimprovememssre not intenAeaoro(fend feature.If,
however,the building or improvement is sold within one yiarofcomple ion,theowner- 'TOTAL:
builder will have the burden of proving Net he did not build or improve for purpose of
aW<J. QTY. PLUMBING PERMIT FEE FLOODZONC APN
❑
1,as be Project
yconaamingwith de!)Theensed Currencies
uracmuro
construct the p snot(Sec.7044,Business and Professions Cade:)The the n ,ma's PERMIT ISSUANCE
License Lawtines such
msn ownerofproperty li licensed
itNorimprovee Hereon and
who coaLudsfor euchpmjenswiN arnnunWorts)licenced puisuenuothe Conmctole
LicexLew. ALTER-DRAIN&VF -WATr3R(EA) FEE SUMMARY
OUTSIDE M-ES
❑nl am exempt under Sec. ,B&P C for this reason BACK ELO OTECT.DEVICE SANITARY Y N
OwnerDate RI?CEIPT#
D S-ILOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby Wfitmthmlhrnance nifcme of mnxnr3o snt Semre,or LMC.)whiof RF.CF:IPTN
FIXTURES-PER I7UP
Wal Cmployee'snWuhis ermit, fed ropy Neraf(Sa.3B0o,LMC.)whit PARK EEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-1 INC.40 S RECISION
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OV 4(: PLANCHECK FEE
❑ Certified wpy is hereby fumhhed.
❑ Certified copy is Bled with the city inspection division. GREASEANDUSTRL WA RCI GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR STRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars($100) SEWS S I AR -STOR .760 ENERGY FEE
or less.)
Icertify that in the performance of Ne work for which this permit is issued,Imall WA .R±V-LM'R
not employ any person in any .Honer so es m become subject to the Workers' PAID
Compensation Lawsof Calife.ia. Date ATER5 RPATI G Date Receipt#
O Z Applicant
zCl NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should JW RESIDENTIAL PLMB. SQ.FT. TOTAL:
[t) become subject to the Workers Compensation Provisions of[be labor Cale,you must
> fomteith comply withmeh Provisions crisis permit shallme
be deed revoked. BUILDING FEL
W SEISMIC FEE
a [�
CONSTRUCTION LENDING AGENCY
U O T hereby affirm Net there is i sunumcc.3 lel,Cis.gency for the performance of TOTAL: ELECTRIC FEE
Me work for which this permit is issued(Ser.7097.Civ.CJ
Lundrirs Name
OLenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I trinity that I have revs this application and state that the above information is MECHANICAL FEE
comct.lagree m comply with all city and county ordinances and state laws relming to PERMITISSUANCE
ybuilding construction,and hereby authorise representatives of this city to enter upon the C'ONSTRUCIONTAX
li V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilities,judgments,casts and expenses which may in any way accrue against aid City AIR HANDLING UNIT(TO 10,000 CFM)
m coasequeSS i,of Ote granting of this pemtit.
— ^ e•�S AIR HANDLING UNIT(OVER'10,000 CFM)
y- - _-`
sx-
Signature of Applicam/Camractor Nr (Date EXHAUST FOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I O(L"BTU) Dam Receipt
Will the.Makam so future building nttupantetere or handle hazardous material HEATING UNIT(OVER 100,IX0 BTU) TOTAL:
as defined by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety
Cate,Sation D532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will
BOILER-COMP(3HP OR I (L"BTU) ISSUANCE DtTb
Nevpplicentmfuwrebuildingoccupantuseequipmentardeviceawhichemit P
hezmdmu au communicate us defined by the Bay Area Air Quality Man¢gemrnt BOILER-COMP(OVER 1 W,"BTU)
District?
❑ FEBa ❑No NEW RESIDENTIAL MECH. SQ.FT. r 81995
1 have read the hazaulous materials requirements under Chapter 6.95 of the '
California Health&Safety Cole,Sections 25505.25533 and 25534. I undcmand the, CII V UI I INO
ifthe building does not currently have a moan,that is is my responsibility an notify the V 1 1,
occupant of the mluimments which..at be met prior to issuance of a Certificate of
Occupancy.
Owner m inalwrized agent Date TOTAL: ISSUED BY:
OFFICE