24742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-MECH N ICACAL 24742
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL. PERMIT NO.
BUILDING DIVISION BUILDING PROJECT IDEN'1'[FICA'I[ON
BUILDINGADDRMS: SANITARY NO. APPLICATION SUBMITTAL DA'I'F.
1-5IW wcca ✓ UNIT LOT# "I"A""
NERS NAME: PHONE: CONTRACT R'SNAMH: LIC NO: N/C CON'1'NOLN
i 4 carts. ZS
RCHITELT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PPPLIA ISSUANCE N$ ❑ X ❑
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GKz Ihercby off in ivisioDumlice Business pro visions of Chaple1 wt iocommencing will JOB DESCRIPTION
0100F Section]II0])o(Division3 of the Business and Professions Code,and mylicrnuis in PANELSfall force and effect.
< W License Clusa yorUP T02IXIAMPS
C1a�',ooy Date umrrvcmr 201-1000 AMPS
zoos— ARCHITECTS DECLARATION OVER I"AMPS SQ. $/SQ.FT.
OF N--W I understand my plans shall homed as public records
aFQ SIGNS ELECTRICAL
YL Licensed Professional O
Kecm<_ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. BU
30.y 1 hereby n.iw that I am exempt from the Contractor's License Law far the
LLOa hdlowingreaaon.Ianut1n]03L5, t,sinewsedve,demolish.
Code:Any city or county TEh1P.METE-It ON POIPINST.
C—yy, whichmyuircsaperlso re aftel,improve, Permit
or repair any structure
C ufa� Printout to issuance,also requires the applicant farsuch permi0o file.signedstatement POWER DEVICES _
udap0 that he i.s licensed pursuant o the provisions of the Contranor's License Low(Chapter
Xoy, 9(cmnmencin9 with Section 7")of Division]ofnhe Business and Profession,Code) SWIMMING POOL ELECTRIC TI
y)_y n hot he is exempt therefrom and the basis the alleged exemption.Any violation of VALUAON
[-. G
Section 7031.5 by any applicant Into pemait subjects the applicunno a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars(g50B).
Q 11I,mowncrofthepropcny,ormyemploymswithwagesasthcirmlecompen.anion, NF.WRPSIDFMIALELECTR _SQ.FT. STORIt TYPE CONSTRUCTION
a3-- will do the work,and the machieisnot iatendedoroffemd Bnsale(See,7044,Business
and Professions Gale:The Commcmr's License Law does not apply to an owner of
propcnywhobuildsorimp r ves thcreen.end whodaessuch work himulforthmughhis
employees,pnrvidedthat suchimpmvemenb arc not intend eduroffienciftwaria.IL OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yeurnfcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
tole.).
❑ 1,mowneroflhe property,sat exclusivelycontranting with licensed cottroctora to QTY' PLUMBING PERMIT FEE FLOOD ZONE gpry
construct the project(Sec.70C4,Business and Professions Cade:)The Contractor's
License Lawdoes not applym an ownerofpropeny whobuildscrimprovesthereon,and PERMIT ISSUANCE
whocommns forrsuch projects with acomramor(s)licensed pursma dto the Convector's
License Law. ALTER-DRAIN&VFNT-WATER HI.)
❑ 1°EE$UMMARY
1 nm exempt under Sec, ,B&P C for this season SI FEF_
BACK FLOW PROTECT.DEVICE
Owner Date SANITARY y_ry
WORKMAN COMPENSATION DECLARATION DRAINS-FLOGN,ROOF,AREA,GOND. RECEIPTM
I heo,by.Iftm thin l have.certiftcateofeamenuo sedf-manna,or a cenificart of SCHOOL TA% y ly
orken'Compensanion insurance or acenifted copy thereof(Sm.3800,Lab C.)which FIXTURES-PER TRAP RECEIPTp
covers all employee's India his permit. PARK FEE Y_N_
Policy p GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Company BUILDING DIVISION FEES
❑ Cenifedcopyisherebyfumished. GAS-EA.SYSTEM-OVER4 EA) PLANCHECK FEE
❑ Certified copy is filed with Ne city inspection division. GREASI?/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(bisection reaction be completed iflhe permit is fminiehundmt do[[.(SIM)
or leas.) FEIi SEWER-SANITA0.Y-STORM EA.200FT. ENERGY
I certify that in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/F.LECfR
not employ any person in any m...to so as to become subject to Ne Workers PAID
z Coml madiom Lawaof C.lifomiw Date WATER SYSTEM/IRFATNG
ApFlicanl Date RecciptN
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr.
P4 became subject to the Worker's Compensation provisions ofthe labor Code,you must TOTAL:
forthwith comply with such provisions or this permit sae deemed revoked.
eithll b
BUILDING IIiE �
Lkl Q CONSTRUCTION LENDING AGENCY SEISM
z 1 hereby afford that is a construction lending agency for the performance of IC Fl-;'
U O the work for which Ills permll is isevesl(Sed 3197,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
0O U lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
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 relming to PERMIT ISSUANCE MECHANICALFEE
building construction,and hereby aahodae mpresenmtivmof nhiscity to enter upon the
above-mentioned property for inspection purpoay. ALTERORADDTOMECH. CONSTRUCTION TAX
G
We)agree to save,indemnify and keep harmless the City of Cupenino against
liabilities.judgments,costs andexpenuswhich mayin any way.cerueagainst said City AIR HANDLING UNIT LTO IL"CFM)
in cousedit the granting of this pewi
�.tL��aaj� � AIR HANDLING UNIT(OVF,R IO,OgI CFM)
Sign near Appy .w.mracror Date EXHAUST HOOD(W/DUCG
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,WO BTU) Dart RcceipTK
Will the applicantor,Munbuildingde,Caparumor handle hamrdhasmaterial
as Code.Section
the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,IXp BTU7 TOTAL:
Cnde.3emion 25532fe)'I
11 Yea 0 N VENTILATION FAN(SINGLE RESID)
Willthe
co tanda insure building by themuseArea Air Q deviceswhichemit
BOILER-COMP(3HP OR 1. W BTU) ISSUANCE DATE
zardosolid? air contaminants m defined by the Bey Arca Air Quality Management BOILER-COMP(OVER IW,000 BTU)
so atria?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. PAD
1 have read The haanrdous materials reyuiicments under Chapter 6.95 of the B
California Health&Safety Code.Sections 25505,25533 and 25534. I undersand that FEB
if the building dnes it-'romenly have n anaa6 tool it is my responsibility In notify the
occupant of Ne reyuirenmas which mast be mm prior m issuance of a C mifcam of 9
Occupancy.
Owner or uulhrrtaed agent Dam TOTAL: ISSUEDBY: �A/� �rCHIII�U
OFFICE