27318APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC I KI AI.
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION,'�IIUII.DIN(:I'ROJEC'1'IDF.N'TIFICATION`
PERMITNO.
g'A 7 /A /�
L r 3 a
BUILDING ADDRESS: T
Z � �/� NIT# LOT If
SANITARY NO.
APPUCAT1ON�SUBBMMfITALDATE
1
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O ER�n+ME. �e P UNE /
'(,LLIC
C...`--I/IiNGINF.ER:
C RACTOR'g�NAME:
rL/IC•NO:
'
NIC
CONTROL #�
ARC NO:
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corrrncr: PHONE
QTY. CLEC IHI PERMIT', FFIR
BUILDING PCRMIT INFO
BLDG ELECT PLUMB MECH
� f4
PERMIT ISSUANCE.
LICENSEDCONTRACTORDECLARATION
1 hereby affirm that 1 E licenvad Lf DECLARATION
9(cammencingwith
Section 9000) of Division 3 ofthe Business d Professions Code, and my license is in
full form and aff
APPLIANCES -RESIDENTIAL
PANELS
JOOBBD ION
�/.�iiRF
1 1 icense Class Lic, p &&Af _ /
UP TO 2IXI AMPS
Dam Contractor
201 - 1000 AMPS
ARCHirECTS DECLARATION
I understood] my plans shall usazed public records.
rstanall b
OVER I IKKI AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
I
j Limnsed Pmax,iomal
OWNER-BUILDERDECLARATIONSPF.CIAI.CIRCUIT'/MISC.
1 hereby eff that 1 am exempt from the Contractor's License Law for the
/v/ I
TEMP. METER OR POLE INST.
1 following wawa (Sodom Business and Professions Cade: Any city aunry
which construct,
uoconseuct,uler,imprave,h
improve. de or repair ny dr,
• its
priormitsrequiresn ser is the permits rile a signedstatement
fthe
POWER DEVICES
that he to the visioscarat
{ the he is licensed parsawt to me provisions of the Conmdors License Lew (shaper
Copourems License La
or(In., ixemith Section 7") it)he Division Sof theBusinessco xsnndpmfeuiov Code)
Sectio 7031.smeltheefmmandlMIasisforlheallegedexemptian.Anyviolationof
Section by any he applicant loacivil penalty of
SWIMMING POOL ELECTRIC
VALUATION
Imo!/�r
OUTLETS.SWITCHES-FIXTURES
than hundred
I more than Eve hundred Dollars (8300).
dollars ($500).
n❑ I,asowneroftheproperty,ormyemployaswithwagcaastheirsolecompensarion,
NEWRESIDFNTIALELECIR_SQ.FT..
STORIES
TYPECONSTRUCDON
will do the work, aniline structure is not intended or official forsale Sa.](M,1. Business
and Professions Code: The Contractors License Law does not apply In an owner of
/
pmpeny who builds or improves thereon, and who does such work himself er through his
fwwle. If.
OCC. GROUP
RPS. UNITS
hoemployees,providedlhatsahimpmvementemenolintendNoroffee
wever, the building or improvement is sold within one year ofcompletwo, the owner -
builder will have the harden of proving that he did not build or improve for purimse of
QTY `r PLUMBINGyPERMIT yPEFlOOU
s i �. '., .e%SANITARY
sale. ),
❑ I,azownereflheWoNny,amexclusivelycmmaingwithlimaedconlmctn I
ZONE
APNconstruct
the project(Sec. ]804, Business and Professions Code:) The.Conarnemrs
PERMIT ISSUANCE
whncooLaw.for such projects wish anmlmtlor(s)licensed pursuunumheConuactora
Lice w Law.
ALTER-DRAIN&VENT-WATER EA
( )nI
am exempt under Sec. , B & P C far this reason
BACK FLOWPROTECT. DEVICE
YN
RIiCEIPI'p
Own DatWORKMAN
RIN)F,AREA, GOND.
COMPFNSATIONDECLAItATIONDRAINS-FTOOR,
�4as7mor,ourviniry, affirm I mormhave a mnificate ofl.p tuo.f(Src.38 ),[..b .)whi,f
Workers'Cmployeasonler this area., nifie0 copy Ch_er$nf (Sec. 3—XIX1, Lnb CJ which
covers all employee's undenhis pertnil. /9
Policy# — "�
TAX Y N_
RECEIPT#
FIXTURES - PER TRAP
PARK FEE. Y
RF(7FTVFdC
GAS -EA. SYSTEM-] INC.4 OUTLETS
BUILDING DTVI. NMES
Company 'i
GAS - F.A. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is bcrchyW.
the
�CcnificJ copy is fled withth the city inspection division.GREASPJINDUSTRL
WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
(Thin section need not be completed ifthe parol is foromehundred dollars ($U)0)
or less.)
SEWER - SANITARY - STORM PA. 20DPf.
PEE
WATER HEATER W/VENT/F.LECIR
I terrify that in the performance of due work for which this permit is issued, l shall
not employ any person in say manner so as to become subject to the Workers'
Compensairml.awsof Culifomia. Data
Applicant
111
WATER SYST /fR1WDNG
Data Receipt#
NOTICE TO APPLICANT:If, after making this Certificate of Exemption, you should
becomesubject to due Workers Compensation provisions of the Labor Code, you
forthwith comply with such provisions or this permit shall M deemedrev
NEW R 1 AL PWIL SQ. FT.TOTAL:
FEE raCONSTRUCTION
LENDING AGENCY
EE1
hereby offirm that there is a construction lending agency for the pe ofTOTAL:
FEEthe
work for which this perm t ss: d (S . 3119], Civ. C.)Lenders
Ndnm
Address
1 cert fy that I have read thus application and state that the above information is
j '�
QTY )MECHANICAL PliRMIT' ); j'FP.P-
s`h'nrrect.
G FEL?Lenders
qPAID
PERMIT ISSUANCE
ICAL FEEbuddingcomoructicn,
I agree m comply with all city and county ordinances and stale laws relating to
and hereby muthoricarepresenetives ofthis city to enter upon the
property for inspection purposes.
ALTER OR ADD TO MECH.(We)
CTION Tabove-mentioned
agree to save, indemnify and keep harmless Ibe City of Cupertino againstIiubilities,judgments,castsand
expenses which may in any way accrue againslsaid City
AIR HANDLING UNIT(TO 10,111X1 CPM)
in consequence ofthe granting ofNis permit.
AIR HANDLING UNIT(OVER By"CFNl
Signature of Applicant/Coomactof Date
EXHAUST HOOD(W/DUCT)
-
HEATING UNIT(TO INIOOD BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date eipt#Will
the applicant or future building occupant store m handle hamrdous materialHEATING
un defined by the Cupertino Municipal Code. Chapter 9.12, and the Ileallh red Safety
UNIT (OVLR I00,IXXI BTU)T
Code, Section a)?
VENTILATION FAN (SINGLE RLSID)
11 Yet,
YcsJ No
WilUhc opplicamorfuwre huildingoccupam useequipmcnt ordevices whichemit
BOILER - COMP LINE OR 100,001 BTU)
ISSUANCE DATE
haraedoos it contaminants as deftnad by the Bay Area Air Quality ManagementBOILER-COMP(OVER
District?
100,000 BTU )
❑Yes
q
A' D
NEW RESIDENTIAL.{'�
MECH. SQ. FT.
1 have mad the la mous materials requirements under Chapter 6.95 of the
Calif ns Health ..fey Code, Sections 25505, 25533 and 255X. 1 understand that
NO
if the bwldinyyyyyy------dddddd nm currently havy�t�r�ant, ymsponsibilirymnotify the
V 21
xcn cots w fi dst In issuance of a Ccnificae of
°
CII _y
BY:
O awharimdagent Dam
- TOTAL: ISSUED
vl-HUt