27632 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OP CUPERTINO ii ILLN iG-F.LF.t-T'RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBROJECTECHANICAL
FICA 2)6 3 2
BUILDING DIVISION BUILDING PRt7h:C1'mN.N'TIFICAT'um r v J(�
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMMMAL DATE
UNIT# LO'T#
OW IAS NnAME: PHONE ��� CONTRACTOR'S NAME: LIC NO:
///�K ����0/f� NIC CONTROL#
RCHITECT iNGINEER: LIC NO: ADDRESS: ❑
'oN'I'ACTN/; //'✓ PH�7P.: 7 /d. - QTY. ELECTRIC PERMIT PER. BUILDING PERMIT INFO
.V CO.G/C 0 f "/ O PERMIT ISSUANCE BLDG F:LF.�T PLUMB ME❑CII
LICENSED CONTRACTOR'S DF,CLA TION APPLIANCES-RESIDENTIAL ls�d��Ll
mozz Ihend difre Nm l am licensed underpmvisionxof CTapmr9(<otmnemingwith JOB DESCRIPTION
Iu 00 Section 7")of f the Business and Professions Code,and my license is in PANELS
t-y�y� full force end
d UPT020o AMPS
Q a Date Contmcmr 201-1000 AMPS /
ZOy� ARCHITECTS DE 10 WW11151 OVER 1000 AMPS SQ.FT.FLOOR AREA MQ.Irl'.
I understand my plans shall housed as public records.
SIGNS ELECTRICAL
Q
Licensed Pronounced
ae�a OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
CX Oapu. I hereby affirm that I am exempt from the Comraatnr's License Law for the
W 3 R-m fo0owing reason.(Section 7071.5,Business and Professions Code:Any city or county TEMP.METER OR POLE.INST.
F�0; which requirese permino conswO.alter,improve,demolish.or mpilr any swewm
Y� primwimissuance,also rtquires the applicant for such permiva file aligned statement POWER DEVICES
o pC that he is licensed puroonuo tire provWinds aline Commune,License law(Chapter
a4�4e 9(commencing with Section 700d)of Division J ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W_rn or thin he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
< Section 7031.5 by any applicantm
fora ismaitbjectathe.,I icanuo.civil penalty of
not snore than f ve hundred dollars($51)0).
❑ I,asowncrofthepmperry,Ormyemployeeswithwagusastheirsolccomperssadon. NEW RESIDEMTIALELECIR _SQ.FT, STORIES TYPF.CONSTRUCfION
0.3— will do the work,and the mums¢isnot intended orof&red forsele(Sa.70,VL Business
and Professions Cade:The Contractors License Law docs not apply to an owner of
property who builds m improves themon,and who does such work himsel f or through his
ownemployces.pmvidedthatsuchimpmvmentsmnotiniendedoroffemdforute.If, OCC.GROUP RES.UNIT
however,the building or improvement is sold withinane yemnfcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ Las owner ofthe property,amexclusivelyaoneraning with llcensW contractors QTY• PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Som.1044,Business and Professions Code)The Committees
License Law does not apply man ownenefpraperty who builds orimpmves thereon,and PERMITISSUANCE
whocoenracts for such projects with acomracmrtil licewed persuanuothe Connectors pLTF:R-DRAIN&VENT. FEE SUMMARY
License Law. WATER(EA)
❑ 1 am exempt under Sou. ,B&P C far this mnso" BACK FLOW PROTECT,DEVICE. 11- AFB
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF.ARF.A,COND. RECEIP #
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y N
❑ Iherebymifrrodatlheveacmiftcamofconsenuo selLinsure.nrocmificatc of FIXTURES-PER TRAP RECEIPT*
Wnrkcte'Compcnsution Insure eont cenified copy thercof(Sec.3801,Lab C.)which PARK FEL' Y N_
coversall e9�'�Y$/ a GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTp
Policy#-/mss/ �Q _ BUILDING DIVISION FEES
Cm uare/�fk+-L.G// F Ea GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
4ECo ed copy is hereby famished,
pitted copy is filed with the city inspection division. GRFASFJINDUSTRL WASTE INTERCEPTOR G ADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
P.
COMPENSATION INSURANCE
(This sectiannced nm becompletedBNe permit is intone hundred dollars($into) SEWER,SANITARY-STORM FA.2061'. YME
or less.) tn
I cenify that in the perfomtanceof the work for which this pewit is issued,l shall WATER((EATER W/VEN'1'/ELECfR ` C
not a
employ any person in tiny m s o as to become subject m the Workers' PAID
Compensmianlnwsof C4lifomia. roma ?R
WATER SYSTEMEATTNG Dam Receipt#
z Applicant
Z0 � NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ. TOTAL:
!-� 00 become subject a the Workers Compensation provisions of the Labor Code,you must
lY . forthwith complyro
with such pvisinna or Nrmit is peshall le deemed mvokM. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that there is a construction lending agency for the pcofornence of
C) O the work foe which this permit is issued(See.3091,Civ.C.) T AL; ELECTRIC FEE
Lender's Name
lemlcra Address QTY. MECHANICAL PERMIT REE PLUMBING FEE
L.) I certify that I have read this application and slate that the above information is
CW., coroner.I agree to comply with all city and county mandates and state laws relating to PERMITISSUANCE MECHANICAL FEE
rF-t building conanumioY,and hereby authorise representatives ofthis city to enter upon the CUNSTRUCf10N TAX
V 7
allm in one J property for inspection purposes. ALTER OR ADD TO MECH.
C (We) to save,indemnify and keep harmless she City of Cupertino against
liabilities d temsemshondexpe mayinan w mese ggyoat dCay AIR HANDLING UNIT(1010,000CFM)
co ofthegren' c L✓.
AIR HANDLING UNIT(OVER IO,gq CFM)
xt
Signa. 'o App end' ommetor V Date EXHAUST HOOD(WIDUCT)
PAID
I IAZARDOUSMATF.RIALSDISCLOSURE HFATING UNIT(TO 100,001 BTU) Data Receipt If
Will the applicant or future building occupant store or handle h eadous material
as defined by the Capons.Municipal Code,Chapter 9.12,and the Health and Safety IMATING UNIT(OVER IOnd"BTU) O AI
Code,Section 25532o)1
El Yea E-)No VENTILATION FAN(SINGLE RFSID)
DYM
Will lair conicmttorfumre buiured by he Bay Am.
Quality
Management
BOILER.COMP OHP OR IOO,gp BTU) ISSUANCE
hesurAoua air mmuntinanrs is aeenma by.he Buy Area Air Quality Manggemenl BOILER-COMP(OVER IOO,U(10 BTU)
'iatrict'! P p a D
Cl Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. p /9
1 have rend the hrrodous materials requirements under Chapter 5.95 of the ##1�� V O
athSafety CWe.Sections 25505.25577and23574. Iundemandthat I�r(�orcuwn.lyh seai c be am e e of a Cenifeum C'7L _sees rIT„� � �1 f! / INOitient S Date TOTAL: ISSUEDBY: U
OFFICE