27604C
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
"U'Llulls1i-ELECTRI AI.
PI.UMBINf.-MECHANICAL.
BUILDINGPR03E:C'1'IDENTIF'ICA'I'ION
PERMITNO.
n 7 C 0 /�
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B LDING ADDRESS: _
SANITARY NO.
APPLICATION SUBMITTAL DATE
Z
UNIT g LOT
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O NIiRS AME: ION '
TR R' AME: L
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CON'TIll
(ARCl11'I I:C'I'/F: GINF.IiR: I N
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❑
CO LC C PHONE: �f
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QTY. ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
ELECT PLUMB MECU
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hembyaffirm Nal l am licensed under provisions of Chapter 9(commencing with
APPLIANCES -RESIDENTIAL
JO FSCRIITION
iorceandof Division 3.f,he Businnaund Pmfessiore Cale. and my license is in
ppryEfS
full
full force and eff q.
License Class LIcM
UP TO 200 AMPS
DoleF{ Canwc r
C '� I
201-ItlIl11AMPS
OVER I000 AMPS
SQ. FT. I100R AREA
S/SQ. FT.
nder d hd
a
SIGNS ELECTRICAL
Licensed P n
OWNER -B ILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I son exempt from Ne Cnmocmex License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city orcounty
TEMP. ME MOR POLE INST.
which requites u permit to construct, alter, improve, demolish, or repair any structurt
prior o its issuance, also requires the applicant for such Permit o file a signed stammem
POWER DEVICES
that he is licensed pursuant to the provisions Of the Catonom's License Law (Chapter
9(commencing with Section 7") ofDivision3 ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or thin he is exempnherefron and Nebasis for Nealleged exemption. Any vlolmimAl'
Section 7031.5 by any applicant fora permit subjects Ne applicant ban civil penalty of
OIIR.FTS- SWITCHES- FlXTURES
not more than five hundred dollars (S50C
❑ I,asownerefNepmNrty,ormyemployeeswithwugesavtheirsoleconpensation,
NEW RESIDENTIAL ELE _SQ. FT.
STORIES
TYPE CONSTRUCTION
will do ilia work, and the structure is not intended orofl'cred torsele(Sec.8144, Business
and Professions Cade: The Conaracmrs License Law does not apply to w owner of
property whobuildsorimpmves Nereaca ormxlforda.,h his
n,and whodosuchwk hi
ownernployms, providedthal such improvementsate not itnendcdorofferedforsals. If,
OCC. GROUP
RFS. UNITS
however, the building crimpowement is sold within one year ofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owneroffle propeny.am exclusively contracting with licensed commnors to
QTY. PLUMBING PERMIT
HTE
FLOODZONE
APN
otuwct the project (Sm. 9014, Business and professions Code:) The Contmcmrs
Licenx law dao not apply m m owner of property w ho bui Ids or i m pmves thereon, end
pERMI ISSUANCE
who contracts for such projects with acormactor(a) licensed puroannothe Contractor's
License Law.
nl
LTER -BRAIN&VENT - W WA EA)
FEE SUMMARY
❑ um exempt under Sec. , B & P C for this mason
BACK FLOW PROTE
OUTSIDE. .P9
SANITARY YN
RECEIPT p
Owner Date
WORKMAN COMPF.NSATecosedDECLARATION
DRAINS - FLOOR, F EAC jX
SCHOOLTAX Y N
❑ thereby affirm that lhave ecenificme of consenun self -insure, orattniMa of
Workus'Compeneation Insurance arta anified wpY thermf(See.3gW, Lab CJw 'Oh
FIXTUR P
RECEIPI'p
PARK FEE Y N
covers all employees under this permit.RECEIPT'
PolicyM
GAS- -1 .ia ETS
g
BUILDING DIVISIO FS
CompanyGAS
❑ Certified copy is hereby famished.
NNN - EA. S!XTt-OVPj1 4 )
PLANCHECK FEE
GRADING FEE
❑ Certified copy is filed with the city inspection division. REASFJINDU WASTE INTER CEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
G SETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be completed ifthe permit is for one hundred dollars ($100) SEWS - SANITARY - STORM EA.200FT.
or less.)
I molly that in the performance of the work for which this permit is issued. I shall WATERT TERW/VENT/F.`CIH
not employ any person in any nat
s as to become subject to the Workers'
PAID
Compensutionlswsuf Coliforms. Date
WATER SYS REATI G
Date Receipt
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENT LMB. SQ, FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or Nis pemdt shall he deemed revoked.
BUILDING FEE _
SEISMIC FEE
CONSTRUCTION LENDING AGENCY I
1 hereby affirm the, them is a construction lending agency for Ne performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lendees Name
Lender's Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify that I have read this application and state that the above information is
sect. la�reemcomply with all city and roomy ordinances end swte laws rcleting sO
PERMIT ISSUANCE
MECHANICAL FEE
buildingconatrucdon, and hereby authorm representatives ofthi 'ty toemerupoa the
above-mentioned property forint tion putpoxs.
ALTORADDTOMECII.
ER
CONSTRUCTIONTAX
(Wc) ee to s indc y e hermle. y uPer into agu ort
x m
liabilities J ostst wu meagainsl said Ciry
AIR HANDLING UNI'T(TO 10," CFM)
in in onseync e e gra g n
AIR HANDLING UNIT (OVER 10,IR10 CFM)
PAID
Sign' real ¢ t/Q tmctar Date EXHAUST HOOD(W/DUCT)
HA'LABBOTS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.000 BTU)
Date Rc ipt
Will the applicant orfmurc building occupant store or handle hazardous material HEATING UNIT (OVER 100,00iTOT
ati defined by the Cupeninn Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Section 25532(e)1
11 Yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUAN rATE
Willtheapplicantorfutumbulldingmcupmntuseeuipmentordeviceswhichemit
azsrdous air contaminants as defined by the Bay Area Air Quality Management
Jistrinn?
BOILER- COMP IMP OR I W." BTU)
BOILER - COMP (OVER 100,000 BTU)
tyaa� q�A7 V p� Ca
PAID
❑ Yes ❑ No
Sections requirements under of the
I have mad the lowSafety
NEW RESIDENTIAL MECH. SQ. FC
J
JAN
Code, I understand Nat
34. 1 un understand
Celifnmil Health do ffi Safcry Code, Sections 25505,25533 it is and responsibility
ethpard dbenosnot M1ave a ter not ify
am, that itismyresurace
^/'r
N r
armsen. nmost
Occupant of the requirementa which must be met prior to iuuence of a Certificate of
of0 of
= JV
awpamey.
ISSUED BY:
Owner or nuthmizcd agent Dote TOTAL:
OFFICE