27494 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL 27494
BUILDING PROJECT IDRN'rIFICATION
BUILDING ADDRESS: _ SANITARY NO. APPLIIC111A'TIIONSUBMITI'ALDATF
554 P21 M Roses UNIT# LOT#
OWNHRS NAMI PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
I� A 14737 296 JOA1ES A 0WR 70 S
RCHITECT/INGINERR: LIC NO: ADDRESS: ❑
203 WOODARD 2D• SA1J J aSti
i CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCC ❑ 1:1 ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL IOBDISCRIPTION
QWz I hereby affirm that l am licensed underpmvisiovofchapter9(camntencing with
¢oj Section 7")of Division 3of the Business and Prpofbssio Codc,tud my,license is in PANELS
FFy�V� lidl farm and effect. 3�1 0-)�'� ��
4F'Zi Liame Class C ZQ LIaM •J •J UP T02(MIAMPS �ly`�
Fjw Dae Cammnor 101-IgIOAMPS SQ.FT.FLOOR AR' S/SQ.FT.
Z O"— ARCHITECT'S DECLARATION OVER I"AMPS
0 Zco"C] I under,umd my plans,hull he toedus public retards.
W SIGNS ELFCIRICAL
Q9Licensed Professional
�Q OWNER-BUILDER DECLARATION SPECIALCTRCUIT/MISC.
CpCOaF I hereby affirm that 1 nm exempt from the Commerce,License Law for the
tY3tz•m fol law ing reason.(Section 703 1.1,Business and Professions Code:Any city or county TEMP.MET ER OR POLE"INST.
which requires a permit o construct alter,improve,demolish,or repair any shucmre� POWER DEVICES W}2 print to its issuance,also requires the applicant for suchpermittofileasignedmm moment
O that he is licensed pursuant to the provisions of the Contractor's License law(Chapter
0. oW 9(cmmncoming with Seerionlf)(10)of0ivision 3ofthe Bminessund Pm(ei'mra Coe) SWIMMING POOL ELECTRIC ���fff VALUATION
yxj_,y Sectio h7031.5 y tberefrnmana the basis permit rhe is theaexemauntto civil Penalty
of OUTLETS-SWITCHES-FIXTURES /
ZQ
Section]031.3I Inydened dont ($50th subjects the epplicannoecivil penalty of r VVV
,T,T nm mrrethunfiveta:popeary.orny 10). NEW RES IDE.MtAL ELECIR _SQ.FT. STORIES TYPF.CONSTRUCION
[p ❑ Lthe wrk,an thesheny,ormyempindedcrohwages forselei(sole compemaios.
L will drthewons Cash: he CorcisnmintLicense
apply
to 7w,Business
and Professions GNB:The Contncmr's license law dos not apply io an owner of
propertywheproorimproves Nampoaementa a,mchwork hirtsterralfrough his
own employees,provided Nm such OCC.GROUP RES.UNITS
pro..menthin ne itnrttdedorof0ed the owner-
mi
net
howevcwthebuilding o improvementisim within one your ofcn,novei for thrower- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
,em.). QTY. PLUMBING PERMIT FLT, FLOODZONE APN
❑ Lv owerofthe Sce.7 .Bantu,.and
The omeronm
Licrowrimmct the Project(sec.loan
nerofI nna Profession,creep)The Commences
whocontracts
etrawdresmm applypmineas rwaernamentls)who
sed ds Frmimp(ovesthe IlEsConation a PERMIT ISS
License racbfursuch projau with arontraaor(s)liccnxd pursuenuothe Contractor AL -DRAIN@VENT-WATER A
License Low, ( j FIiE SUMMARY
❑ I am exempt under Sec. B @ P C for this reeaon B CK FLOW PROTECT.DEV ICE MARY Y DE N
Owner Date RFCEIPI'p
WORKMAN COMPENSATION DECLARATION RAINS-PLOOR,ROOP,AREA,CO SCHO TAX Y N
❑ Ihereby affirro,ou l have.cenifcamafemuctm s u-motre,ma anificaeW FlXTURIS-PER TRAP RECEIPT#
Workeri Compensation Insurance or a cenificd copy thereof(Sec.3800,Lab C.)which Q�jPARK FE Y N
policy 11 empluYee';unllryhleycvrgl4O O RECEIPT
IAJCi G. GAg-GA.SYSTEM-1 TNG 40UTL:
BUILDING DIVISION PEES
Company JD GAS-EA.SYSTEM.OVER 4( PLANCHECK FE+
Certified copy is hereby famished.
Cerified copy is filed with the city inspection division. GREASLIINDUSTRL WASTE, tRCEPfO GRADING ITE
CERTIFICATE,OF EXEMPTION FROM WORKERS' REASETRAPSOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Him permit i,for one hundred dollars($100) .WER-SANITARY-. M !A.200 . ENERGY F .
or less.)
I certify that in the performance ofthe work for which this permit is issued,l shall W TER HEATER WNI LE
not employ any person in my roamer so as to become subject to the WorkersD
Z Compensation Lawsof California. Dam WA SYSTEMITREATING Dam Receipt#
Applicant
rz C NOTICE.TON'PLICANT':If,after making this Cenilicete of Exemption,you should NEWR. DI3NTIAI,PLMB. S TOTAL.
.2 became subjecno me Worker's Compensation provisions of the lobar Cade,you muss
tY > forthwith comply with such provisions or this permit shall be named invoked. BUILDING FEE -Q
C4 Q CONSTRUCTION LENDING AGENCY SEISMIC HE t
z Ihereby affirm mat hem is a construction lending agency for the Performance of TOTAL: ELECTRIC TEF.
O�•+ the wad for which this pati,i,issucE(Sec.309],Civ.C.)
C1. t^ lender's Name PLUMBING TEE
O U Lender's Address Q'I'Y. MECHANICALPERMIT FEE
I certify That 1 have read this application and.1.1.that the most,infotntirn is
6i toted.l agree to comply with all city and county ordinances and stale laws mining to PERMIT ISSUANCEMECHANICAL FTE
buildingeoruwction.and hemhyautho(ve exp rsentatives ofthis city memo upon the
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
�-t (We)ugrco m aovq Indemnify and keep hatless the City of Cupertino against
IiuM1ililies,jutlgmenm,cabnndexpcnses which may in any way.arue ngnin5i said City AIR HANDLING UNIT(TO 10,000 CFM)
sequence of thetit rD7(
taco ��1 AIR HANDLING UNIT(OVER IO,IIg)CFM)
au, k',= J�n1r� as I-a6 9y
Signamreo Applicant/ tractor Date U14AUSTHOOD OODUCD _-j/�• �3Z
PAID Jam_(.]
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Receipt#
Will the applicant or future building occupant store or handle hazardous matednl ❑EATING UNIT(OVER 100,000 BTU) TOTAL:
as def nen by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety 69.4-6
Cmle,Sati 25532(e)'r
El Yes ❑No
VENTILATION FAN(SINGLE RESID)
❑
ISSUANCE DATE
WilUheupplicanmrfuwre buildingacupant u,eequipmem or J<viceswhich emit BOILER-GQMP(3HPGR Ifq,IXNIBTU) � p
humrdnus air contaminants as defined by the Bay Are.Air Quality Management BOILER-COW(OVER 100.800 BTU) M
nishnP (k' 4#qN
❑Yes 11 No NEW RESIDENTIAL.MECH.—SQ.FT. JAN ^`a 1.(�7.7(]
5
1 havc end the hazardous materials requireeats under Chapter 6.95 of the
California llerllh@Safely Code,Sections 25505,25533 tend 25534. I understand that Cllr Ur VureHIINU
if the building does not currently have a mount,that it is my responsibilitym nnotify the
acupunt of the Iequlmments which must he met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE