27992 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERTINN ILDI O-FLECTRI AIPERMIT NO.CITY OF CUryAPPLICATION/PERMIT PLUMBING.-MECHANICALOsoBUILING PROTECT mNNTRA
27992
EUILDINsA(f'��Q�R[11tSS' 1 •1^/..�rJ�1\{/g�1�J SANITARY NO. APPhICATION S^U/ByMI�T�aTAL DATE
Y V� l U Tp L r:h f —Z gr
O R ME: PHONE: �i1�iA 0 `A Q 1 J t N/C /CELL CONTROc,L# ll•J
RCI TECl/ENGI E LIC NO: ADDRESS: U 6F — ❑
107
26
O' PH BUILDING PERMIT'INFO
\ ^ QT Y. ELECTRIC PERMIT FEE
BLDQ ELECT PLU B ME
PERMIT ISSUANCE ,pCX�,
LICENSED CONTRACTOR'S DECLARATI N APPLIANCES-RESIDENTIAL
I heron firm that l amliccnxedunJer fCha19(aummadem Ih JOB DESCRIPTION
C1=7 Ya Pnrvisionso per bwi
mOO Section RIIXB of Dinumn 3 mf the Business and Professions Code,and my license is in PANELS
yfull force and effect.
Fz hicen.cc Class LL.# 1 UPTO2MAMPS ✓
m¢a Date Contracmr 201-I IXp AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
F,�L ARCIIITECTS DECLARATION OVER IOW AMPS
pO 1 understand my plans shall bo used as public records. w ^w
0ta_W SIGNS ELECTRICAL
Q Y j Licensed Professional \
C
sQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/nUSC.
XOaU 1 hereby affirm that 1 um exempt from the Contractor's License Law for the
W3v-rFir following trim,. (Seaton 7031.5,Buait rofessions Code:Any city or county TEMP.METER OR POLO INST.
F=
c,< which re vires a run,alter,imps e,demolish,or repair any xieucmm
SYS p' nususuance..1,copross the applicant to uch permirtofileasigned statcmrnt POWER DEVICES
ww�b at he is licensed minart,unhe pre visioncoq Carnes,License Law(Chupter
SWIMMING POOL ELECTRIC
dXm�
(commencing with Sec0on]f1fN)of Division fthe Business and Professions Code) �` VA U�1f3f _
ty_y or that he is exce,armrcfromond the basic fee l ollegedexempum Any vial ation of IJrt'-SWITCHES- `�Lx+
_ZQ Scaion]03L5by anyap,rcant for.,enritsuh cis the appllcammacivil penalty of MIXTURES -
not mare than five hundred dollars($500). VVV
fZ0 NEW RESIDI:NGALCLECTR SQ,FT. STORIES TYPE CONST'RUCTION
KF_o ❑ I,mownrk, propeny.or notinurded i offered
sacibe(Sed.7044,Bu cion,
a3°-° wind hewor, J m'sLndede ofvdoes no,
In W,Business
and .,.C act
license ,ow does not aPPly to an owner of ,
pm, wh one, rovrxdmre ,and o suchworkhimsefforthruughnis OCC.GROUP RES.UNITS
n ided lhatsuchim menet are nmimionhai rofferedfor.sale.If,
In III
ni,o,umaosm im'tn one yuvofcompluion,the,wna- 'OT'
builder' 'll no a the burdenro ving that he did not build or improve for puffs)%c of
sale} ,
❑ Lns,wneroft ropeny,an exclusively contracting with licensed contractors m QTY' PLUMBING PERMIT FEE FLOODZONE APN
, ry 'cl the pct' 't(Sec.9(94,Business and Professions Code:)The Contnmmrs
Licens.iaw sm.t.pplyloanownerofpropenywhobuild,mimproves there on,and PERMITISSUANCE _
whocon a for such projects with a conneaor(s)licensed pursuant Contractor's pLT1iR-DRAIN&VENT-WATER(EA) FEE SUMMARY
Lic Law.
1 am exempt under Sec. .B&P C for this reason FEES-
BACK FLOW RO '.DEVICE: OUI SIDE
SANITARY Y N
Owner Date DRAINS-F OORROOPA A.GONDRECEIPI'p
WORKMAN COMPENSATION DECLARA , ,
'nON . SCHOOLTAX Y
❑ Ihcrtby affimtthadl haveacenifimm ofconsem to ulf-insure.oracenifeme of Fl%TU -I'CR TRAP �� RECHII'T#
Wmkers'CompenvdoninsumnecoracenirtMeopytherrof(Sec.3BW,Lab CJ which PARK FCB Y N
rsall employe.',under this permit. GAS- .SYSTEM-1 INC.4 OUTLF. . RECEIPT
Poll, BUILDING DIVisi NFEES
Company GA EA.SYSTEMO 4 I PfANCHECK FEE r�
❑ Ccnified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. FASEANDUSTR TE CEPTfR GRADING 101E
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRInW N, SOILS FEECOMPENSATION INSURANCE
3j
(This action aced not he completed iRM1e pemdit is feature hundred dollars($1SEWER-SANY-ST 1iA.2001". IiNERGY la;F,
,r le".)
I certify that in the performance of the weak for which this Permit is issued.I shall WATERH .RW LECIR
,in,employ any pens any m as,,become sabjet, w the Workers' PAID
Compensation Law.cof Calif,mla. aDate so WATER EMITREATING to Receipts,
O Z Applicant
Z Q NO3'ICE TO APPLICANT:If.after making this Cenificate of Exemption,you should .W RESIDE LPLMB. SQ FT. TOTAL:
r ^ become sabjcmao the Worker's Compensation p-,isioos of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemW revoked. BUILDING IrEE
W Q CONSTRUCTION LENDING AGENCY SF.ISMICITiE
I hereby a(frm Ihaubcm is a comtruction lendin6 agency for the performance of
Z IiLECTRIC F.E
V �-
O the work for which this pe—it is issued(Sec.3Wl.Civ.CJ \
Lender's Name PI.UMBIN FEE
C F Lenders Address QTY. MECHANICAL PERMIT FEE
U I cenify that 1 have read this application and state that the above information is MECHANI AL FEE
>" connect. I agree to comply with all city and county ordinances and state laws Mining to PERM IT ISSUANCE
Cj) building construction,and hereby amborise representatives of this city to enter upon the CONSTRU ION T'AX
U Z above-mentioned pro y for inspects, ur,ow, 2 ALTER OR ADD TO MECH.
(We)agree o ave indemnify and f harm) s the Ctry of Cupertino against
liabilitie,jud u,costs an swh nmay any way account against said City AIR HANDLING UNIT(TO 10,000 CFM)
con e ,f the grary t fNn,pconi
AIR HANDLING UNI'I'(OVER IU,f1W CFM)
S natur nf)ApplicanVCu ntomr part EXHAUSTHOOD(W/DUCD PAID
( HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Reecipt#
Will the applicant or future building Occupant store or handle harandoas material HEATING UNIT(OVER IW.000 BTU) M1
as definuJ by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety TOTA
Code,Section 25532(a)] VENTILATION FAN(SINGLE RISID)
❑Yes ❑No
Will the applicanmr future building neupaml use equprit nt a,devices whi.b emit
BOILER-COME CH P OR 100,0110 BTU) ISSU -
havrdous air contaminants as defined by the Bay Area Air Quality Menagcmenl BOILER-COME(OVER 100,000 BTU) MAY 4 egg
Dom.? 5
❑Yes 11N, NIiW REN
SENTIAh MLCH. SQ.FT.
I have read the hazaMous mmcdals requirements under Chapter 6.95 of the CIIY ur 1
Caltmerma Health&Safety Code,Serious 25505.25533 and 25534. 1 understand that UU�1/NO
ifthe building does not currently have a taunt,that it is my responsibility to ouri'ythe
nonfood of the"ornaments which must be mel prior to issuance of a Cenificate of
Occupancy.
Owneror amhori'rsnl agent Date T ISSUED
OFFICE