27696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ICIJI .-EL.6 RI,AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING FROG CT]DENNIFIC 27696
BUILDING PROJECT IIJENI'IFICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�r(fy�(.F/t}J SINYp IDT#
OWNS NAME: 8P}jONE:w� C NT13@CfOR'S NAME: LIC NO:
w9IIJ YY YY IVa '1/ NIC CONTROL p
RC ITT Cf/ENGINE'R: LIC NO: DD W S: ElDXry SS ',loll
oNTAC1': PHONE: BUILDING PERMIT INFO
�/���sFI,���.#�a��� o`1// QTY. ELECTRIC PERMIT FEE.
✓CI" PfN4 � q95-60= PERMIT ISSUANCE LDG 1:LE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIFT10
�00 Ih7").lfirmrhm l 3 oft he Business and Profession Castle,
9nt)(commencing with � �
00 Sectionereby or Division I3nlice sed Business and Professions COJe,) my licenseis in, PANELS
yv EIC full humanist effect.
QV'Z License Class Lie.4 UPT020JAMPS
vF'ia Date Contractor 201-IOWAMPS
1-osZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
Zorn" IunJcnwnJ my plans shall be used art public records. OVER IOW AMPS
CZ CI
y C: SIGNS ELECTRICAL
q��dd License)Professional
50� u OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xn O: V I hereby affirm than 1 am exempt form the Commences Cs License law for the
W3av<i which rests sa. erval to co3L5,Business and pr Professions Code:Any city samenury TEMP.MEIER OR POLE INST.
C uu,OanJ which reyuiresa permit to cOnvrvc,,abet,improve,demolish,or repair any swcturc
f s°}� prior to its issuance,also requires the applicant for such pemtitto file n signed Statement POWER DEVICES
<p that he is licensed pursuan, .,be provisions of the Contractors license Law(Chapter
e. 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
p^,to or that he is exempt herefrom and Ne basis for the alleged exemption Any violation of OUTLETS-SWITCHES-FIXTURES
F_Z Q Section](131.5 by any applicant for a permit subjects the applican to u civil penalty of
$< not mom than five hundred dollars(5500). _ .FT.
M [I I,osnwneroftheprnparty,ormyemployeeswilhwagesastheirselecompensation, NEW RESIDENTIAL ELECIR SQ
STORIES TYPECONSTRUCTION
y will do thework,and the sametureisnot intendedoroffened for sale(See.]044.Business
and Professions Code:The Contractors License Law does not apply to an owner of
property whomildsorimprovesthereogand shames such work hureelfor,hrough his
OCC.GROUP RES.UMTS
own employees,provided that such improvementsart nut intcndudmoffered for os it If,
huilder ,will
have
the
b r improvement is sold within one yearor improve
for t purpose
r.of TOTAL:
builder will have the burAen of proving that he did not build or improve for purpose of
ante.). QTY, PLUMBING PERMIT FEE
❑ I,ns ownendthe property,am exclusively umnuaing with licensed camrvetors to FLOOD LONE APN
construct the Mint(Sc,7044.Business and Professions Code:)The Commctors
Licenmlawdmsnotapplymanuwnerofpmpcnywhobuildsorimpmvesrhemon,end PERMIT ISSUANCE
whocontracts forsuch projects with a coracloHs)Ilcensed pursuant totheContmetor's ALTER-DRAIN&VENT-WATER(IA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec.' .B&P C for this rtasnn OUTSID
E Mig
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner —Date— #RAINS-FLOORROOT.ARCA.COND. RECEIPT#
,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IhembyafOrtnthat l have acenificateofcmma to self-insumora cenificale of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a cenified copy thcreof(Sec.3800,Lab C.)which PARK FEE Y N
coven all em In ee's under thio t. RECEIPT#
employee's porml GAS-EA.SYSTEM-1 INC.4 OUTLETS BU ILDING DIVISION FE ES
Policy#
Company GAS-EA,SYSTEM-OVER 4(A) PLANCHECK FRF.
El Certified copy is hereby fumished.
❑ Certified copy is riled with the city impection division. GREASRflNDUS]RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGRPASETRAP SOILS FEE
COMPENSATION INSURANCE
('this section need not bn completed lithe permit is forme hundred dollars($]N)) SI7WER-SANITARY-STORM EA.200FT, ENERGY FEE
mlesa.)
I certifythut in the perfmcfanceofthe workforwhich thiepemmit isissted.1,1W) WATER HEATER WNF-NT/ELECfR
not employ my person in my manner so m to become subject to the Workers PAID
Compemution Lawsof California. Dam WATER SYSTEM/TREATING Date Receipt#
z Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDEM'IAL PLMIL SQ.FT. TOTAL:
F'
city became subject to the Workers Compensation provisions of the Labor Code,you must BUILDING FEE
F!X 7 rostrums ith comply with such provisions or this permit shall he deemed revoked.
6Wi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that is a construction lending agency for the performmce of
U zTOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.C.)
Iznder's Name PLUMBING FEE
O Lender's ertiAddress QTY. MECHANICAL PERMIT FEE
L) 1 cfy the,I have read this application coil state that the above information is MECHANICAL FEE
>1urrent.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
4 c
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
L) Z above-mentioned property for inspection purposes. ALTERORADDTOMECIL
(We)agree to save,indemnify and kap harmless the City of Cupertino against
iabilitienjudgments,costsand expenses which may in my way wermeagaimt mid City AIR HANDLING UNIT CFO 10,000 CFM)
in consegom of the granting of this perm i
Z w AIR HANDLING UNIT(OVER 10.0110 CFM)
6=1
Signuture of AplicamiCommatt.1 Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Date RecxiptN
Will the applicant or future building occupant store or handle hurnedous notarial IIFATING UNIT(OVER 100,(100 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2 532nd? VENTILATION FAN(SINGLE RMID)
❑Yes ❑Na
BOILER-COMPQHPOR IW,0009TU) ISSUAN DAA i D
Wi1l,heepplicoorand.um building by he tum equipment Quality
an igemeit �1NjJ+
hazardous air conmminms m defined by,he Bey Arca Air Quality Management BOILf:RCOMP(OVER 100,000 BTU)
District? es DEC 2 Lq%
❑Y ❑No NEW NTI
RESIDEAL MECH. SQ.FT.
I have mad the havrdous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. I understand Na, CI I I '
if the building does no,currently have a tenanLTou it is my responsibility to notify the Vf F+Ur t INQ
oecupmt of the nyuimrands which most Ito met Prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE