28366 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
tlNLBING-ELECTRICAL
CITY OF CUPERTINO PLUMBING-ELECT ICAMECHANICAL PERMITNO
28366
eoaumc Drvlslory APPLICATION/PERMIT
BUILDING PROJECT IDEN'tlFICA'1'ION
BUILDING ADDRESS: �.�,lJ SANITARY NO. MIT
CT
DAT
2 ✓ UNIT. LOT# �r
OWNER E: PHONE: CONTRACTOR'S NAM LIC NO: r
N/C CON'TROLp
"1C11iNGI "ft: LIC NO: ADDRESS: ❑
CONTACT: P O E:
QI'Y, ELECTRIC PERMIT FEE BUI/ILIB[_EDD_I{N�NGPEPER/}MIIlwTT INFO
LD e
PERMIT ISSUANCE
LIdonloaDce... CTOR'S DGCLARATION APPLIANCES-RESIDENTIAL r
pyz, Ih700B.Mis,nti amliecnsedinessard Pmfnsof Chapter and mmenense with JOB DESCRIPTION
�a WEE FenSeeton iteffct. pn3ofthe Business and ProfessionsCWe,and my license is in PANELS
,U W Lie force anti effect t
Fy� Dace se Class Contractor-
201
T02W AMPSPRO
�' F4m 201-IOW AMPS SQ.FE FLOOR $/SQ.Fir.
OO=Q ARCHITECTS le CT$DECLARATION OVER IOW AMPS
FF I d Professiandonal
my plans shall be usrA as public records. `es
("'rn❑„�j SIGNS ELECTRICAL
LL..l Licensed Pro(esstonal
OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
�pp,,�aF I hereby affirm Ban I an exempt from the Contractor's License Law for the
3�m following reasom(Section]OJLS,Business and Professions Cade:Anycily orcounty TEMP.METER OR POLE INST.
C which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its Issuance,also requires the applicant fprsuch pennluo file a signed statement POWER DEVI
Cep that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapar
d a�' 9(Cammeneing with Section 7")of Division 3 ofthe Businessland Professions Code) SWIMMING ELECTRIC VALUATI
W_m .r that he is exempt thcre(romand the basis for me alleged exemption.Any violation of �rD
�z4
Section]831.5 by any applicant for a permit subjects the applicant to a civil penalty of UTLETS-S -S-FIXTURES
m
s�q not ore than five hundred dollars($5W). N
W m ❑ 1,asownerofthepmo ny,ormyemploywswithwagesastheirsolecompensation, NEWRESIDENTIA, A __SQ.FE STORIE TYPECONSTRUCI'ION
E522 will do the work,andthe strucwmis nm incended proffered forsaie(Sec.]094,Business
and Professions Code:TM1e Camractor's License L doe of apply to an owner of
progeny who buildsarimpmves thereon,and who Des suchw khimmlfonhrough M1is
ownemPloyees,pmvldedthat suchimprnveme xxcnolincend orpflbred foc."e.if, OCC.GROUP RES.UNITS
however,the building or improvememissel ithinore yearof< PleliFthepwner-
builder will have the burden of proving the did not buildor i r ve for purpose of
1 TY. PLUMBING PERMIT
erefthepropeny, exclusive) traain Q FEE FLOOD ZONE
ycan gwith tic xedconvnctorsm APN
C
'tract thenproject(Sec. ,Business and Professions Code: The Cantracmr's
L nse Lawdoesnm toanosoc fp perrywM1a baudition vesthereogand PERMIT ISSUANCE
obecontractsfor c projeelswithacontra tors lih<risal pursuant the Contramor's
limnm Law. / ALTER-DRAIN&VEINY-WATER(PA) FEE SUMMARY
❑ I am exam t under Sec. B&P for this reason OUTSIDE FEES
I BACK FLOW PROTECT.DEVICE
Owner
SANITARY Y N_
�e DRAINS-FLOOR,ROOF,AREA,COND. CEIPI'#
ORot CO fNSATtI f.sem. N_
�� SCI{OOL TAX #
Iherebyaf thatlh��_aveppp ctif atE ofpss�imia mlF Itrt;o certificate of FIXTURES-PER TRAP
.rkers'Compen moan ins NUCTa Dopy thereof ec.38W, bCJ which PARK FEE N__
coveriallemploy 's a J h E p
Polcy# r/-k a GAS-EA.SYSTEM-ZINC.40UTLETS �.
Company -�' BUI BION FEES
❑ Certified copy Ih1mbylllrul roti. GAS-EA.SYSTEM OVER 4(EA) PLANCHECKF
❑ Ceridusle.pri fled wi h city impart ndivision. GREASUINDUSTRL WASTE MINCE"; GRADING ��
CERI ICATEOFEXEM ONFROMWORKERS' GREASETRAP SOILS FE
COMPENSAT NINSURANCE 2 /�
(Thissectionnee notbecomplet iflhepemtitisforonehundreddollam($IW) SEWER-SANITARY-STORM EA.200FL
or ENP,RGY E
Icertifymeninthe rrmm iftheworkknohich Nis permit is issued,i shallWATER HEATER W/VESIVELECfR
not employ any person manner so as to become subject to the Workers T PAID
z Compensation Lawsof Califomia. Date WATER SYSTEMITREVHNG oto R iplN
C O Applicant
z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET TOTAi:
r4become subject m the Worker's Compensation provisions of the Labor Code,you must
tai , forthwith comply wi th such provisions or this permit shall Is,deemed revoked. BUII 1 E
W 4] CONSTRUCTION LENDING AGENCY S E tb�
7-. I hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sm.3097,Civ.C.) IC FE
40 Lender's Name
0 Under''Address QTY. MECHANICAL PERMIT FEE - NGF E
U 1 certify that I have read this application and state that the above information is
Caren, legree rocomply with all city artd county ordinances and state laws relnling to PERMIT ISSUANCE MECHANIC FEE
I,.) building construction.and herebyamM1orize ovprescs filumcirymenterupmvbe
(, Z above-mentioned prupecty for inspection purposesALTER OR ADD TO MECH. CONSTRU ON TAX
(Wc)f moo m save,
in
m�ify and keep facta City of Collector.against
liabilities, gments, s" expenses who yin wayaccfue agninst,md City AIR HANDLING UNITGO I0,000 CFM)
an use 1140 the r if of this perm.
_ AIR HANDLING UNIT(OVER IgpW CFM)
Signature
f pplicanUCammcmr Dam EXHAUST HOOD(W/DUCT)
\,�C PAID
HAZARDOUS MATERIALS D CL USE J HEATINGUNIT(TOIW,OWBI'U) Date ceipt#
Will eapplicantor future building occupant stn diel zarJous material
as defined y the Collection Municipal Code,Chapter 9.12, d the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Sec n 25532(e)]
❑Yes 0 N VENTILATION FAN(SINGLE REBID)
BOILER-COMP(3HPOR 100,000 BTU) ISSUANCE D
Will the ecoicammfture building by die Bay A .Air Quality Manah Callgement
PAID
rdous air comaminanu as deFincd by Ne Bay Arca Air Quality Management gO1LER-COME(OVER 100,000 BTU)
❑Yea ON. NEW RESIDENTIAL MECH. SQ.FT. Vb1 � �
1 have read thm
e bardous materials require !1!
requirements under Chapter 6.95 of the 1995
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that r
if the building does not currently have a tenant m b L/(Jr
that it is my responsibility notify the CII I
occupant of the requirements which must be met prior m issuance of a Cel tifienm of �yylsaz /l'`F I
Occupancy.
Owner in ambprired agent Dale TOTAL: ISSUED BY:
OFFICE