27850 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELEC FR .AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICALn O C 0
WILDING PROJF.Cf[DENTIF'ICA1 ION G of
BUILDING ADIIRGSS: I/ //y� 'Q)F //� //�/ SANITARY NO. APPLICATION SUU'B�/'MIIITTAL DATA
S I QIP UNITNV /Q O(�V LOT.
/0_
/O 0
OW�€RSj�AMI:' PHONE: CONIR OR'SNAME: LIC NO: NIC CONTROL0
L TCt�iOn Orli - 6
00 w e�
ARClllq'CCTIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. IiLECI'RIC PERMIT FEB
Coo e r Qg PS 6pep — PERMIT ISSUANCE
BLDG ELECT PLUMB MECIi
f$
LICENSED ONTRACPOR'SDECLAhaphs 9 pppLIANCLS-RLSIOENTIAL )OR DESCRIPTION
pyy Ihcrcby ufErvision amlicensedBusiness
imfiximt Code andna,license with
{s1�0 Smionemalefecivision3of the Business end Professions Code,and mylicrnse is in PANELS �� ��
F U full fnrce lass effect.
FZw Lamm Class C.a, UP T0200 AMPS
IV-)Z-
.<,a. Date Commctor 201-IMM AMPS
Z FOr`r,z' ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLUOR AREA SISQ.FT.
Cl Z—O I understand my plans shall be,used as public records.
r44,1 SIGNS ELECTRICAL ^ ' /O
a Licensed Professional0C
OWNER BUILDER D[C ON SPECIAL CIRCUIT/MISC
Oa V 1 hereby affirm that I am exemContra
pt Tom the Contractor's License Law for Ne
3 W H fallowing rwvm.(Sation]031.5.Business wd Professions Cade:Any city or county TEMP.METER OR PoLF.INST.
,W0; whichrequimaapemritncoms the applicant
plicor trash statement
C WAC) that proorte
slicensede.duent to the proisioantftheor Coch permiuo BleaseLaJ amtemem PoWER DEVICES
iKOp� Nm heislirenudpursuantm00 )of iiisiof the Conusines and
Pro Lown,Cody
Pa5Wide 9(rommencing with Scnion]0(10)of DivisinnJof Nc Business onJ Professions Code) SWIMMING POOL ELECTRIC VALUATION
a orthmh7031.5by themfmmand Nebermitss for bjealleged exemption,
toMylPenatylation of OUTLETS-SWITCHES-FIXTURES / ��/, 603e —
Y
Section LS by anY applicant for the applicant to penally of
G not more Nan live hundred dollars(S50B.
CFG p Nny,ormyemployeeawithwagesm N<irwlecomp oration, NEWRFSIDENT1ALELECTR _SQ.FT.
5Po ❑ Les ownemOhe STORIES TYPE CONSTRUCf10N
a will Pr the work,and Coca: be Cmdroractum m.,a License offeredsnot apply 9044,Business
and Rvfessions Code:The Comrumr's License Law docs not apply m an owner of
property who builds or improves charter.and who does such wad himselfor through his
employces,provided that such improvementsam not intendedaroffemd forsale.If, OCC.GROUP RTS.UNITS
however,the building orimpmvemcnt is sold within one yearofcompletion,theowner- TOTAL:
hander will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ l.as wncrofthepropcny,amexclusivelyconu gwithlicensMcontrectomto QTY. PLUMBING PERMIT FE F DZONE APN
construct the pmject(Sea 7044,Business and Professions Code:)The Comment's
Licenu Lawdoes not opplyto an ownerafpropertywho builds or improves thereon,and PERMIT ISSUANCC
who contracts far such projects with a conwumr(s)licensed pursuunuo the Cornractoes
License low. ALI 12R-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this moron BACK FLOW PROTECT.DEVICP. SANITARY Y 111EES
th
Owner Dom RECEIP #
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPFcale of10NDBCLARATION SCHOOL TAX Y N
❑ th'Cmb nmtioninsu a oracemenfcomsemtoof(Sec.38W, bC.) Wchcof F]XTURES PER TRAP RECEIPI'N
WorkmcoverslCmployeeawarerlux,ntrit. ified copy Nertof(Sec.J800,LubCJwhich PARK FEC Y N
covers all employee's under Chia permit. GAS-G.SYSTEM-1 INC.4 OUTLETS RECEIPT'p
PolicyM BUILDING DIVISION FEES
Company GAS-F.A.SYSMM-OVER 4(EA) PLANCIIECK FEE
❑ CenifiMcopyisherebyfurdshed.
❑ C<nificd copy is filed with the city impaction division. GRWF41NDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE.
('Ibissection meeJnotbe completed Hite permit is fromm hundrddo11rs(5100) SEWER-SANITARY-STORM PA.2011FT. ENERGY ME
orless.)
I certify that in the performance of Ne work for which this Permit is issued,I shall WATER HGTER W/VCNTIELECIR
not employ any person in any manner so as to become subject to the WorkersPAID
z CompmmdmLawsof Cdifomia. Date WATER SYSTEMnVEATING Pam Receipt
Applicant
� Q NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
D� become subject o the Worker'a Compensation provisions of the labor Code,you must
a 1 forthwith comply with such Provisions or this permit shall be domed revoked. BUILDING FEE /
[>a [M CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which Nis permit is issued(Sec.3097,Civ.CJ
Landes Name
I s
O IxndAddress QTY. MECHANICAL PERMIT FEE PLUMBING FEE
certify d to 1 have read thlc application mixture that an move information
ng is
r�" RWi cnrrtt'l. legrtc to comply with allay anJ county ordinances and state laws existing to PERMIT ISSUANCE MIiCHANICAI.FEE16971
building construction,and hereby ordnance representatives ofthis city menter upon the CONSTRUCTION TAX 6
V z aWvpropertyentioned property for impection purposes. ALTERORADDTOMECII.
.-r X.o.say.e,.,d , ndemnify and keep harmless dhe City of Cupertino against
Iiacend expenses which may in my waywcmea ainstsaid City AIR HANDLING UNIT IT 010,000 CFM)
inthe t gof Nis permit.
/wAIR I IANDLING UNIT(OVER Io,0o0 CFM)
icantlContacmr Of Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 103,"BTU) Date Receipt N
Will the the Capeant or Mu building occupant Chntstemoe handle Health anatormous d
Safety
m defined by the Npmino Municipal Cede,Chapter 9.12,and the Health end Safety HPATING UNIT(OVER 100,000 BTU) TOTAL:
Cede,Section 25532(ul]
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3117 OR Io0."BTU) f3e4
DATE
Will the applicant orfmurcbuilding occupant use equipm<mordeviees whichemit 44�� e4 B a
hacandaus air connotation es defined by the Boy Ara Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? 13 Ym ❑No NEW RESIDENTIAL.MGCH. SQ.FT. OCT 91A(]r
1 have mad the harmdom materials requirements under Chapter 6.95 of the G�1( /JJJJaaDD
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that / Ut- LUf„t
il'Nc It In docsmt cunemly have a tenanWhat it is my responsibility to notify Ne 11
ac pun airuir�wy m<t prior t/Q (� ryf� f
(lbaberoracthodrzdagem gI`�_��� / Date TOTAL: ISSUED BY:
OFFICE