27170 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B HAI G-ELECOUCAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27170 a�1 0'
BUILDING DIVISION BUILDING PROJEC'FIDEN OF.ICA]ION,- G
BUILDING AUDRF'_ti5: /��—'f.f l� SANI'fARV NO, API'LIG'DON SONMI'ITAL DA'I'I?
�V-�/'� (C- l_� ' UNITq LOT O
OWNS AMI?:el E�ltJoe 1 _ PHONN,:�_/� ONTNACTOR_J;AM� LIC NO:
II''ffll`/x/''YYUU✓✓ 11``tt// I lXJ N/C 7DN I RO p
CHI � Ili GNLLR: LIC NO: DRESS: ❑
CONTACT: L6 PHONE: QI.Y ELECTRIC PERMIT FEE BUILDING PI?(iMIT INFO
BLDG .ECT PLUMB 7PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-BESIDE NTIAI. 108 DESCRIPTION
pKz I hereby affirm that l am licensed under provisions of Chapter 9(commencing with
Poo Section 700h of Division 3 o the Business and Professions Cale,and my license is in PANELS
aZU full lnse Clas efl'cet. UP TO 200 AMPS
pd.,Zul License Gloss LIc.X g
asQy Date Cmdracmr 201-11X10 AMPS
20usz ARCHITECT'S DECLARATION OVER I"AMPS SQ.Ff.FLOOR AREA 5/SQ.FT.
C z Q I undenwnd my plvns shall be used us public records.
Ern W SIGNS ELECUITCAL
44 Licensed Professional
mJ yY 2 U< OWNER-exempt RDEC ContraON SPECIAL CIRCUIT/MISC.
L�4OaU I hereby affin,r.(Se that I am exempt fmm the Contractor's License Law for the
W3my lollnwing ruunnr(Seniun]BlLS.Business and Professions Code:Any city nr county TEMP.METER OR POLO INST,
C C,; which requires it permit 1.crown a.into,,improve,demolish,or repair any structure
}� priori its issuance,also requires the applicant forsuch permit to file a signed statement POWER DEVICES
u�4 O Nut he is licensed personal to the provisions of Ne Contractors License Low(Chapter
4.W o 9(wmmening with Section )ef Division3of the Renitent aA Profesionx Cade) SWIMMING POOL ELECTRIC
VALUA'T'ION
that he is exempnh iefronand the basis for theollegeA exemption.Anyvialiamr.1' UTLETS-SWITCHES-FIXTURES a,1C I
tzQ Section 9031.5 by any epplicamfar.permit subjec.ftripplicnnt toecivil penehy of
� O nal more Nan five hundred dollan($500). NEW RE.SIDENTIAh F.LECfR
4411 pm ❑ I,asownernftheproperty,ormynnpinyeeswithwagesastheirsolecompcnsmioo, SQ FT. STORIES TYPE CONSTRUCTION
1 will dothe work,and the structure is not intendedmidered for sale(Sec.]044,business
and Professions Cale:The Contractors License Lew docs not apply to an owner of its
properywbobuildswurproves Ihemon,and wbodoessuchwork himselfoMmugh his
cmployces,provided Nauuchimpmvements:ve notimendedararfesed forsule.If, OCC ORD PO
N'
however,the building or improvement is sold within one yew of completing the owner-
wild,,
wned
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[3I,as owner ofthepropcny,amexclusivelyconracting with licennedwm
rnctors to QTY. PLUMBING PERMIT PL•E ON s
awsbuct be project(Sec.7044.Business and Rofessions CnJeO The Contractors
License Lawdocs not apply to on ownerol'property who huildsor improves thereon,and PERMIT ISSUANCE
wbocontmetsforsuchprnjemwiNacontrnetor(s)licenu puruanito Ne Cmmnetoes ALTER (EA)
License law. FEE,SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason OUTSIDE ILPS
BACK FLOW PROTECT.DEVICE ANTT Y YN
Owner Data DRAINS-FLOOR,ROOF.ANEA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION 8 OOLTAX Y N
Iherebyaffrmthalhuveacenifcmcof consemmself-insure.ora certificate of FIXTURES-PP.R TRAP PARK
'orkers'Compensation l murance or a certified copy thereof(Sec,9800,Lab C.)which PARK FEE Y N
rs all employees under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT M
Policy X BUILDING DIVISION FEES
Company GAS.EA.SYSTEM-OVER 4(EA) PLANCHIiCK FEE
❑ Cmifnl cagy is herchy furnished.
❑ Certilied copy is fled with the city inspection Jivisiaa GREASFANDUSTRL WASTE INTFRCHVI OR GRADING FEL
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS PER
COMPENSATION INSURANCE
(This,ceno meedwa be cinmefol ifthe permit is forme hundreddullarsDrift) SEWER-SANITARY-STORM EA.208FT. ENERGY EEE
or less.)
I certify Nm iathe performance of the work her which this permit is issued,Ishall WATER HEATER WIVENT/HLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califemia. Date WATER SYNTENY BEATING Data Receim#
O Z Applicant
C) NOTICE TO APPLICANT:If,after melon this Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.IT.
8 P TOTAL:
,F
Become hwithc subjecttothe Walkers Compensation provisions his Lation
Code,you most
� ; forthwith comply with such provisions or permit shell be deemed revoked. BUILDING FEE
0. Q CONSIRUCTION LENDING AGENCY SEISMIC FEE
7 z Ilumdynffirm Nwthcm is aeranumetion hwdingagency for the perfarmance of TOTAL: ELECTRIC FEE
U O the work for which his permit is issued(Sec.3097,Civ.C.)
4, � lander,Name c, -
QTinders nedrc.. Q'I"Y, ?. MECHANICAL PERMIT FEE PLUMBING FEE
U L verify that I hav ad Nis application and site that Nc above information is
>' Li. cored.Iagre mply ith all city and county ordinances and state laws relating to PERMIT ISSUANCE
MECHANICAL FEEE-' � nn building o u n hereby unicorn representatives ofthis city recover upon the
U z above-n lionpro yfor' law purposes. ALI 17R OR ADD TO MECII. CONSI'NUCTTON TAX
%Ve e to e.i cmnif and keep harmless the City of Cupertino against
It. ides,' c t o ande reaswhichmayinanyway cemeagam, id City AIR HANDLING UNIT(TO IO,TXXI CFM)
tonne cane herain Nis permit.
AIR HANDLING UNIT(OVEN W.
"CPM)
S' oat of ApplicanUCmm�ctor Dare EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Reeeip,#
Will fac.,licowar future btildingoocupant,a.eor handle LacaMous material ryEATING UNI'P(OVER 100,000 BTU) T A
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health rid Safety
Code,Section
0 Yes ❑No
25532(¢)? VENTILATION FAN(SINGLE RISID)
BOILER-COMP(3HP OR IfxI,000 BTU) ISSUANCE DATE
Will Otenpplicanlorimurebuildingacupant useequipmemnrdevices which emir ! ^
sardwx air m morwanta as defined by the Bay Asea Air Quality Management BOILER-COMP(OVER 100,00OBTU)
grin?
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT.
I have read the heeerlous mnverlals requircrai under Cha ear 6.95 of the CT 1 1994
L
rnia Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand thatsbuilding does not currently have a tenant,Thar it is my msponothility to notify Neant.1 the rcquircntents which must he met pear to issamm ofa Certi6eate ofancy.rmimaludmd.geal Dat. TOTAL: ISSUED BY:
OFFICE