27637APPLICANT TO FILL IN INFORMATION WITHIN RFO I INFSi _ LICF-RAI 1 OnINT OWNI nMl v
CITY OF CUPS PLUMBUILB NG
sTory APPLICATION/PERMIT NG - MECHANICAL
BUILDING DIVISION
PERMIT NO.
27637
BUILDING PROJECT IDENTIFICATION
1
BUILDING ADDRESS:
LOT#
SANITARY NO.
APPLICATI/O1N� SUBMITTAL DAM
I r, 1 {►f.
ow i o f
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431tN/C
"L*_SLk
CONTROL#
ITECl/E WEER: LIC NO:
A
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
B T:LECT PL MECN
�tDrCsrL(
PERMIT ISSUANCE �.
LICENSED CONTRACTOR'S DECLARATION
Z Ihereby 70dE fDivisatl amlice Business p1Parons mairms epter9nd no,Ho se with
O full Section mad of Division 3 of Ota Business and Pmfeseions Code, and my license is in
UG full tome and effxL�
ty License Class LIC.#
y Dale Commoner.
APPLIANCES -RESIDENTIAL
��g DESCRIPTION
- `(�
RM
ppprELg
UP T0200AMP5
201-I000AMPS
Z ARCHITECTS DECLARATION
M 1 understood my plans shall be used m public records.
SQ. FT. FLOOR AREA •
$/SQ. PT.
OVBR 1000 AMPS
SIGNS ELECTRICAL
j Lsensed Profersiorel
SPECIAL CIRCUIT/MISC.
J OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
Gfollowing reason. (Section 7031.5, Business and Professioru Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit in file a signed satement
that he is licensed pnmua d w the provisions of the Contractor's License Law (Chapter
X4 9( commencing with Section]000) ofpivision 3 of the Business and Professions Code)
N or than he is exempuhercfrom and the basis for the alleged exemFlti.n. Anyvanati.aof
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not more than five hundred dollars ($500).
z ❑ I,asownerofthepropetty,.,myemployeeswilhwagesmtheirwlecompmation,
will do the work,and thestructure isamintendedorofferedfnrsale(Set.]044,Businese
VALUATION
OUTLETS - SWITCHES - FIXTURES
r- IEWRESIDENTIALELECM_sQ,FT.
STORI
TYPE CONSTRUCTION
and Professions Code: The C.nlmctm's License Law does not apply t. an owner of
property who bui Ids m i mpmves thereon, and who does such work himself or through his
ownemployees,providedthmmchimpr..�.tserenotintendedoroffcmdforsale.If.
however, the building or improvement is sold within one yearofcompletion, theowner-
builder. will have the burden ofpmviag that he did not build or improve for purpose of
sale.).
OCCGROUP
RES, UNITS
QTY- GPERMIT FEE
PERMIT
El LasnwnerofthepmNay,amexclusivelyconmwtingwithlicensedcon=yc w
construct the project (See. 7044, Business and Profession$ Code) The Commerce,
FLOOD ZONE
A=
License Law does not apply to an ownerofpmpeny who builds or improves thereon, and
ERMITISSUANCE
who contracts for such pmjec a with a coduclor(s) licensed pursuant to the Con
License Law.
❑ I am exempt under Sec. , B & P C this reason
LTER- DRAIN&VE T -WA ER (FA)
FEE SUMMARY
FLOW PRO EVIC
OUTSIDE FEES
OwnerDate
WORKMAN COMPENSATION DECLARAT ON
Thereby alfirm thmlhave acenifiwy of consent wself-ins ere, oracertifcateo
.rker%Comceruati.n Insurance or eccnified copy thereof (Sao i80LLa Jwhi
Envoy all employee's under Otis permit.
Policy p
INS -, 00 ,A A, ND.
SANITARY YN
RECEIPT#FLO
SCHOOLTAX Y N
RF.CEIPTM
X.I. RTMP
PARK FEE Y N
RECF.IPf N
G -A SYSTEM -1 C 4 OUTLETS
Company
GAS -EA. SYSTF.-OVER4(EA)
BUILDING DIVISION FEES
❑ Certified co herebyfamished.
py is
PLANCHBCK FEE
❑ Certified copy is fiIN with the city inspection division.
GREASEBND TRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
REASEAAP
SOILS FEE
(This sectionneed am be completed ifdom marit is for.., hundred dollars($100)
or Iess.)
R - SANITARY - STORM PA. 200IFT.
ENERGY FEE
I cenify that in theperformance ofthe work for which Nispemrit is issued, l shall
not cmpl.y.aay person in any manner so as to become subject w the Workers
Compensation Lawsof CelifOmla. Dow
Applicant
WATER HEATER W/VENT/ELECTR
-
PAID
Dale Receipt#
WATER SYSTEM(IREATING
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cods, yaa must
forthwith comply with such provisions or this permit shall be deemed revoked.
NEW RESIDENTIAL PLMIL - SQ. FT.
T
BUIL DINCITE
i�
CONSTRUCTION LENDING AGENCY
1hereby affirmthat Here is construction leading agency for the performance of
the work for which this peissued is (Sec. 3097, Civ. CJ
Lenders Name
SEISMIC FEE
�—
ELECTRI �.
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBI
1 certify that I have read a lication sad state that the above information is
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
MECHANICALFEE
correct I agree...mply w' all cit and county mdinances and slaw laws minting to
building construction, and rebyau rixerepresematives.f thiscitywenleruponthe
above-mentioned property or ins on purposes.
ave
( agree to s, demnif and ken harmless the City of Cupertino against
CONSTRUCTIO AX
liabili es, dgmenn.cost ande asesw may in any way imemesgainstsaid City
in co sNu are of the in this pe i
(�'A 1J
VV ^jDam
AIR HANDLING UNIT (TO I0,000 CFM)
AIR HANDLING UNIT(OVER I0,000 CFM)
—
Signa fApplicaaUConlract.,
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
A] the uplicanmr future building recupant sore or handle h tiscouus material
Dam Rece t 9
T TAL:
as a ed by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Co , Section 25532(a)Y
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
❑Yes 11 No
WilIm.-PPI icant., furore huildingoecupem useequipmenmrdevices whichemit
BOILER- COME(3HP OR 100,0011 BTU)
ISSUANCE DATE
�mooua air comaminame as defined by the Bay Area Air Quality Management
BOILER - COME (OVER I(q,ODO BTU)
❑ Yes ❑ N.
1 have rend the haanrdous materials requirements under Chapter 6.95 of the
Celif.miu Health & Safety Code, Scott., 25505, 25533 and 25534, 1 undersand that
if the building does not currently have a octant that it is my responsibility to notify the
occupant of the requirements which must be met prior w imwnce of a Certificate of
Occupancy.
tars
/gB
li
{7 1�
0r L
u
BY:
NEW RESIDENTIAL MECN, SQ. FT.
Owner or amhonmd agent Date/I
ISSUED
OFFIC