27724APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING -ELECTRICAL I PERMIT NO.
CITY OF CUPERTINO PLUMBmO-MECHANICAL 277241 � � n A
BUILDING DIVISION APPLICATION/PERMIT G L 4
' BUILDING PROJ4:C'1' IUEN'I'IFICATION
p
—/ — 64,21 X
ARCUITECTRiN (NEER: LIC NO: ADR SS: ❑
cooaQ, �ACT: PHONE:Q9'Y. ELECTRIC PERMIcar T ?E BUILDING PERMIT INFO
T'. f9
PERMITISSUANCE BLDG ELECT P{IB MECII
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES - RESIDENTIAh _
IOB DE
SCRIM
I not af0ethat l am licensed under pmns
visioofChupter9(commencing with SCPTION
,sRI
m
NON Seen.. 7W of Division 3 of the Business and Professions Cade, and my license is in PANELS
6F z{full force and effect 000
ILLU'.1 License Ch a birth or 4 - UP TO 200 AMPS
m G Dote Camrart�r® 201 - 1000 AMPS
'ZOyz' ARCHITECTS DECLARATION OVER 1000 AMPS SQ. Fr. FLOOR AREA $/SQ. FT.
O! _ O I understood my plans shall be used as public records,
Fy�LL] SIGNS IiLF:CTRICAI. '
Urro dProfcssionul
y a'6 OWNER -BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O a V 1 hereby offirm that I vis exempt from the Connors License Law for the
a WrEu following mason(Section 9031.5, Business and Professions Coda: Any city or county TEMP. METER OR POLE INS' I.
� 0; which requires a Fewer to container, ober, improve, demolish, or repair any structure
% >� prior to its issuance, also mquimstheapplicant forsuchpeimiamfileasigncd marcmem POWER DEVICES
Wall that he is licensed pursuant to the provisions of the Contractor's License Law (Charier
Y P.o9(rnmrationg with Section 9000) of Dl vision 3 of he But tons and Professions Cole) SWIMM I NO POOL HLECTRIC VALUATION
XIy❑y or that he is exempt herel tom and the basis for the alleged exemption. Any violation of OUTLETS -SWITCHES-FIXTURES �/
4.Za Stolon 9031.5 by any applicant fortpermitsubjects the applicanno a civil penalty of ///Ir
�'0 not more than five hundred dollars(5300). NEW RESIDF.NTIAh ELECTR-SQ.FI'. I/v
M
❑ Lasowncrofthe property,ormy cmployeeswith wages as theirsolecompensution,S'T'ORIES 'TYPE CONSTRUCT ION
d will do the work.and the structure isnot intended oroffered forsule(Sec. 7044, Business
and Professions Cade: The Commcmrs License law does not apply to an owner of
property who milds m ierproves thereon, and wm dmssuch work himself m through his
con employwv, pnrvidW the suchimprovementsure not imm�deaoroffered forselo.IL OCC. GROUP RIiS. UNITS
however, the buddingor improvement is sold within one year ofeompletion,the owner.
TOTAL:
builder will have the burden of proving that he did nos build or improve for purpose of
m4J.
❑ I, as owner ofnhepmpcny,am exclusively rnmmcaing with licenvul contact nrsm QTYPLUMBING PI?RMIT = A ac, aNEP. " A FLOODZONE AI'N
continue, the project (Sec.'L)44, Business and Pmfrssi.ns Cade:) The Cwhowmrs
Limnselawdmsnotapplytomownerofpropenywhobuildsorimpmvesthereon,end PERMIT ISSUANCE
who Ionones for such projects witha emanclm(s) licensed pursuant home Contractor's
License Lou, ALTER - DRAIN&VENT - W .RUA) -FEESUMMARY'
❑ I am exempt ..or, site , B & P C for this reason BACK FLOW PRO 'I'ECT. DF ICE 017I. ID , d:
SANITARY Y N
Own, Date RECEIPT N
DRAINS - PLOOR,ROO ANI?A, COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ IherehyafRrmthmlhummer nificate.fcomemmsfrSen. re,of a Loth
C.) Which
Fl%TURKS - PERT RRCEII9'N
Wmken'Campenaatimn lruurvncenmmiifeJ ropy thereof (S<c.3g00, Lab C.)wbich PARK FEE Y N
p�all empinya's un der It 't. GAS-EA.SYS-IINCAOUTLETS RECEIPT#
rspryp 6 BUILDING DIVISION FEES
CnmpunGAS-EA. STEM-OVERS(EA)SPL CHECK ITE
fami
❑ Certified copy is hi famished.
a.
copy is riled with the city correction division. GRED ✓INDUSTRL WASTE INTERCEIGRAD GFir,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE SETRAP OILS FEE
COMPENSATION INSURANCE
(This secllntimoM not be completed ifthe permit is forms, hundred do][.P1110) SEWS -SANITARY- .A. FT. ENERGY FRE
.r less.)
I certify that in the perfmmanceof the work for whichthis permit is issued, Ldmil I WATF.RH TER N -LECTR
not employ troy person in any manner so as bject u.the Workers' PAID
Oz uns'tio .cos of,
f C,lifnmia. Dam �� WATER SYS /fRRATIN Date Reccipap
ZFICE TO APPLICANT:If. after making this Cenificam of Exemplion, you should NEW RFSIOENTI PLMB. SQ. FT. TOTAL:
became subject a the Workers Compensalian provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
0.Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
V ZI herebyuffirm thmthrmmion iso whomlending agency for the predominace of ELECTRIC FEF,
ne work for whichtbrm
is pela is issued Sec. 3099, Civ. C.) TOTAL:
th
ILi Lender's Name "' - a , PLUMBING FEE
F Landers Address QTY. 'MECHANICAL PERMIT FEL'
U I certify that I have read this implication and same dim the above information is MECIIANICAI. FF,E
W correct. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction, and hereby nation. represenmtivesof this city raw antipso the CONSTRUCTION TA%
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We) agree t. save, indemnify and kap harmoss the City of Catarina. againn
liubilities,judgmems, costs an nseswhte i may in any wayaccme egainesaia City AIR HANDLING UNIT (TO 10,000 CFM)
In cons'eTc roof the gr ego is e It.
AIR HANDLING UNIT (OVER 10," CFM)
re of AP mcor R Date EXHAUSTHOOD(WNUCT7 PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU) Dam Recript0
Will the tiplmr, Ctiam.rfu Municipal Code,
Charm, 9.
noir le the acerb is and Sae,, BEATING UNIT (OVER 100,000 BTU)
'
as Jdined by the Cupenin.'Mtnicipal Coda, Chspmr 9.12, snA the lleahh and Sefcty 1'OIAL:
Cole, Section 25532(a)9 k�.,VENTILATION FAN (SINGLE RESID)
EIYn GNo
BOILER -COMP (311P OR Fill BTU) I�,f UAN 6TE
Will the uppllcamor Gtmro building.ccupum useegsipn¢m ordaviocs whichontit 1" �i
I c 1 m nnn�u /as defined by the Bay Area Air Quality Management BOILER -COMP (OVER 100,000 BTU)
lisone, a air n a APR 25
❑Yea �No NF.WRESIDENTIAL MECII. SQ Fr. � 19g5
1 have read th Zr us nationals requirements under Chapter 6.95 of the CIlY 1 a%
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
inhebnt .1 taint rte ru hBy Iho ave to t. tuna itmmy rctp.ntmuity to notify me UI• LU�FHTI
occupant building
iremenu whi musnaem1 nrmihaspsomh`co(e enifotohe
Oc panty. at
er or amhoroW ,gen fate TOTAL: ISSUED BY: