27451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO.
CITY OF CUPESIO NO APPLICATION/PERMIT PLUM ROJECTF.CEANIFIC
BUILDING DIVISION BUILDING PROJECT IUEN'TIFICA9'lON 27451
BUILDING ADDRESS: �76 ' } W (L SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT If
OWNERS NAME: 6 12 PHONE: CONTRACTOR'S NAME: LIC NO: INAJJ
N/C CONTROL#
ARCHITECT/ENGINEER; I LIC NO: ADDRESS:4. � J{ /_� ❑
coNTnCT: /(a Ow�y PHONE: �♦ QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
i Capp 1�P9 ag Iw` �d"y`e/YP BLDG ELECT PLUMB MECH
/ PERMIT ISSUANCE g 1:1 0 11
LICENSED CONTRACTOR'S DECLARATION APPL4WCES-RESIDENTIAL !'� TOB DESC IPI'ION
cmz I hereby affirmthat l amns
liteed underprovoions ofaunderf)commencing with '7 a
F�00 Section]000)of Division 3 of the Business and Professions Cede,add my license is in PANELg t I YJ
y� full force end effect _� UP 70200 AMPS L
F Z W License Cla Lic.p
F'a, Date Contractor -fS f y 201-1000 AMPS
ZOrNi,Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ. .FLOOR AREA $/SQ.En
O Z^q 1 understand my plans shall be used as public recortls.
ti
SIGNS ELECTRICAL
QY „ Licensed Professional
�K�QOWNERBUILDER DECLARATION SPECIAL CIF1
k04 F I hereby uffrm that I am exempt from the Contractor's License Law for the
W 3 WO m following reason.(Section 7031.5,Business and Professions Cede:Any city or county TEMP.METE R FIST.
rn which requites a permit to construct,men.improve,demolish,or repair any structure
i� ptiorto its issuance,also requires the applicant for such permit to file a signed statement POWER DEVI ::11
ty A O that he is licensed putxuant m the provisions of the Convector's License Lew(Chapter d s' Cy
a o�' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL LECfRIC ' 9�QpVALDA ION is
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS ITCHES-FIXTURES 1 , /
Section 703 IS by any applicant for a permit subjects the applicant m a civil penalty of
G nm more than five Iandred cards($500). 1 V r r �Gh �,abs � roaM
mC31,.s..ne,.flhepropeny,ormyemployeeswithwagesasibeirsoleempensation, NEWRESIDENTIALELECTR _SQ. J6TORIES TYPE CONSTRUCTION
s willdothe work,and thesmmoure is not imroubsi roffered for sure(Sec.]044,Busimas -\`I I
and Professions Code:The Contractor's License Law does not apply to an owner of 3 2
property who builds mangroves thereon,and who does such work himself or through his
own employees provided thmsuchimprovemenuarenotimm�dedorofferedfrreale.If, OCC. ROUP RES.UNITS
however,the building or improvement is sold within one yearmmmplelion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownero'theproperly,amexclueively contracting with licensed contractors to QTY. PLUMBING PERMIT 7H FLOODZONH APN
rostrum the project(Sec.7816,Business and Professions Code:)The Concretion's
License Law dcesnot epplyto anownerof property whobuildsorimprovesthereon,and PERMIT ISSUANCE
who contracts nonsuch projects with aerntmear(s)licensed pursuant to the Conedwa's ALTER TIS
(LA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. R&P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
SA Y Y N
Owner Date DRAINS-FLOOR,ROOF,AREA OND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a cenlficate uncritical to self-insure,or a certificate of FIXTURES-PERT P RECEIPT'#
Workers'Compensation Insurance or acertifted copy thereof(Sec.3800,Lab CJ which PARK FEE Y N
vers all emplo�eEs ygd�+ s Qermil. RECEIPT#
cover'ad
C.11 NN l GAS-EA.SYS -1 OITfLLTS BUILDING DIVISION FEES
Company a �- I { GAS-EA.SYST -O 4 UTA) PLANCHECK FEE
Certified copy is hereby famished.
Certified copy is filed with the city inspection division. OREASEANDyw WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sertmesed imbe completed ifthe Fednilis far one hundreddollam(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I cenify that in the penamuoceofthe work For which this Permit is issued,Ishan WATER HEATER W/VENT/ELECIR
not employ any person in any mermer so as to become subject to the Workers' PAID
Crmpensatian Lawsrf Cmifand., Date
z. Applicant WATER SYSTEM/IREATING DateReceipt#
O -
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ FT. TOTAL:
V) become subject to the Whitney's Compensation provisions of the Labor Code,you..at
a forthwith comply with such provisions m this Permit shall be domed revoked. BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz 1 hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEF.
O the work for which this Permit is issued(Sec.309],Co.CJ
pLender's Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICAL FEE
.Fi building construction,and hereby authorize repccentativesofthis city to enterupon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
F7 (We)agtw m save,indemnify and keep harmless the City of Cartoon.against
liabilities,judgmenu,costs andexpenses which may many way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the grunting of this Pen .
AIR HANDLING UNIT( VER 10 CPM)
Signature of Applicam/Commctar Date EXHAUST HOOD(
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI BTU) Date Receipr#
Will the applicant or future building occupant same or handle hazmdaus material HEATING UNIT( R100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Colo.Section 255532(a)4 R�N VENTILA N FAN(SINGLE RESID) I
PISISSUANCE DATE
Wlllthea Ilcamorfuture buildin BOIL6 -COMPCHPOR IW,0000TU)
pp g by the Bay Are. en Quality
ccs w agement
M1azondrus air cnmaminants m defnetl by the Bey Aree Air Quality Management
Distinct? BOILER�COMP(OVER 100,00(1 BTU)
11 Yea PiNm NEW RESIDENTIAL MECtI. SQ.FT.
I have read the hazardous mmerims requirements under Chapter 6.95 of the
if
uil Ing dM1s Safety Code,Sections 25505,25533 andsponsi (understand that APR •�
if the building docs not currently w have a moan,,that is is my responsibility m notify the H I�
nccupam mile,rcquiremencs which must be met prim m issuance of a C nificaid of '
Occupancy, a
Uggi
Owner or amhorized cit Dam TOTAL: ISSUED BY:
OFFICE