27357 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIR:DINfrE1;ECTHICAI. RMI'I'No.
APPLICATION/PERMIT 1'LUMISING-MRCIIAM1'ICAh
RUILIPN(i IfMgION BUILDING PROJECT IDEM[FICA'1'[ON 27357
ILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATI
UNIT# LOTH
N. S AMI:. PfIONF. CONTR O ' NA L': I .NO:
N�/CC CONTROL4
( I� Tf: iN I iE LIZ ]ADDRESS' ��%3M yT�
COMA PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE. L LE P - MI:
�N9L[lY_ G—�sA_IIV-J�1'.I/ E
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
OzZ Ihereby of@m,noI an licenwdunderprovisions adChapla9(Imaromcing with TOB DESCRIPTION
W02 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
LVF full force lass effect.
aIle Liccnse Class Lic.# UP TO 20D AMPS
h<d D:nc Commcmr 201-1000 AMPS
FyZ ARCHITECTS DECLARATION SQ.FT.t100R AREA $/SQ.IT.
Z O w Z OVER 1000 AMPS
OZ—❑ IunJcrslanJ my plans shellbouseddpuhlic rccoNs. a ��.a/�
t W SIGNS ELECTRICAL {�l••�li
Qy$j Licensed Ptofessi...I
E:=W< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOiU I hereby afrom that 1 am exempt from the Connector's License Law for the
m3 LLL following reason (Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. G
F-LLOa which requires.permitw construct,Am,,improve,demolish,or repair any........
YS prior In its issuance,also requires the applicant forsuch Permit o file a signed statement POWER DEVICES
Ibat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
D SWIMMING EL[CIRIC
aXe 9(cummencing with Section 1000).(Division 3ofthe Business and Professions Code) VALUATION
m—rn or that he is exempt herefmm and the basis for the alleged exemption.Any abandon of FI%TURES
SWITCHES-
(-ZQ Section 703 IS by any applicant for a Permit subjects the applicant to a civil Penalty of OUTLETS-
n .,amnm than five hundred dollars(5500). NEW RESIDENTIAL ELECIR _SQ.FT.
C[� ❑ 1,asownerofthepfopM.ormyemploymswlthwagesaslheirsolecompenvdon, STORIES TYPE CONSTRUCTION
y312 will do drew.d,andflocoucmren
ism imeadetim.ffered fmadc(Sec.]044,Business
and Proressiuns Code: Me Connector's License l.aw does nal apply to as owner of O
property whoboildsorimpruvesthereon,and wbodoes such workhimsdfortlwughhis
own employees,provided that such improvemanim,notinmade4orofRrW formic.If, OCC.GROUP RES.UNITS
however.the building or improvement is sold within one yew of eomplioma,the owner-
builder will have the burden of proving that he did not build or improve for purpone of
sella.). QTY. PLUMBING PERMIT FEE FLOOD ZONE- APN
❑ I,us owner of the proPeny,am cxduxivelyconuading with licensed cuntr.cmrsm
construct the project(Sec.10W4,Business mJ Professions Code:)'Ihe Contractors
License Lawdoesnotapplytoanownerufpropeny who builds.,improves thereon.and PERMIT ISSUANCE
who cermet%forsuch projects with acontmomr(s)licensed pursuant in One Contractors se Law.
License
ALT1iR-DRAIN&VF,NT ) FEE SUMMARY
❑ p am exempt under Sec. .H&P C far this reason BACK FLOW PROTECT p OI SIDE I'I:ff%
SANITARY Y N
Owner Dom RECEIPT#
DRAINS-FLOOR,ROOF,AR
�/ rs WORKMAN COe.iiN5AT10asom1. RATION SCHOOLTA% Y N
Ih'Comp firm lhal Insurance
oramul a copydmof(Secure.or Lab C.)whiof 1:1X'1'ORES-PER'IRAP RECEIVI'p
oilers'Cmployee'innper thin mracenifieJ copy @ertol(SeeJBW,Lab C.)which PARK PF.E Y N
rovers.11 employee's under this permit, GAS-EA.SYSTEM-I INC`40 ETS RIiCEII'I'N
Policy N BUILDING DIVISION FEES
Company GAS-P.SYSTEMOVER 4(EA) PLANCHECK FEE
❑ Cenified copy isherchyfumished.
❑ Certified copy�is filed with the city inspersion division. GRIiASI%INDUSTRL WAS F11 IMT F;1 GRADING FEEFTOTAL.
CLLTII'ICATIi 0I:F.%[MPTION FROM WORKLRS' Gft1iASE TRAP OILSIEIiCOMPENSATION INSURANCE
(phis section need not be completed ifNe Permit is for one hwdred dollars(gIW) SEWER-SANITARY-ST ORM HA.2(11117. I2RGY IEE
m less.)
I certify that in the Perfommuce ofthe work fm whichthis pemlit is issued I shop[ WATER HEATER W/VENTP'-LECTR
nm employ any person in any manner so as to become subject to the Workcn' PAID
Connftmoom nlawsofCalifomia. Dae WATER SYSTF.MiTREATING Dam z Applicantz 0 NDIICETO APPLIC,ANT:IL aper making this Certificate ofEaemption.you should NEW RESIDENTIAL PLMB. SQ.FT.
P
(/l become subject to the Workers Computation Provisions of @c Labor Code,you must
forthwith comply with such provisions or this pemm shall he deemed revoked BUILDING F
C4 >
LW 0. Q CONSTRUCTION LENDING AGENCY SEISMI
C z I hereby affirm that hem is a construction lending agency for the performance of ELfiCfRl P.'
U O the work for which this pernit is issued(S .3091,Civ.CJ
I<nder's Nun, PLUMBING ME
0 F 1,ender's s. QTY. MECHANICAL PERMIT FEE
O Uenify chat 1 ha a rtaJ is epplicaion end state that the above in(omu0on is MECIIANIGI.1 iF.
't.la to ly wit Il city aM county oNinenca andna,lawsrelatingto PERMIT ISSUANCE
a' buil ing conn, tion, nlle uwhorim representatives of this city to enter upon le, CONSTRUCf10 A%
Oz xho cWe)agre tos ind sif,and luupharmless
ar ALTER ORADD TOMECIi.
(We)al n . 1indc lanced kap harm le ss the Cityof cre against
oid Citi
Iia lities,jud nu, os and xpenus which may in any way accrue agairel said City AIR HANDLING UNIT(TO IO,IXp CFM) 1
c tnegaence Ithe ,ring fthis Permit.
01(
� A AIR ItANDLING UNIT(OVER IgINro CFM)
ureo
Sign: f App icanl/ moor 1 Dide E%HAUSTHOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE ORATING UNIT(TO IIXt,(1CO BTU) Dam And p
Will the ap loan,or boom building occupant store or handle hazardous material TOI'Al.:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilerlth unit Safety HEATING UNII'(OVER 100.OBU BTU)
Code,Section 25532(a)F VENTILATION FAN(SINGLE RESID) -
❑Yea ❑No
ISSUANCE DATE
BOILER-COMPCHPOR W.00DB9'U)
Will Fair contaminants
is as define by the
Bay equipment lout Management
;Nous lir<nnmminants as defined by the Bay Area Air Quality Management BOILER IW,o006TU) NGS/
ries, f g
Cl Yes ❑No NEW RESIDENTIAL.MECII. SQ.FT. �� � 1(,
I have ad the hazardous materials myuimments under Chapter 6.95 of the Vf L / k779C
re
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that �p 1, k�
Bthe building docsnmcm
oely have.moa .That it is my responsibility,,ratify the Ff
occupant of the requirements which nmst he met prior to issuance of o Cenificam of
rl �/%'7Vol'ceupmmy.
Owneror auth.nud agent Dale ISSUED BY:
OFFICE
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