27778 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELEC'TRICAL
LLBUILDING
PESIO NO APPLICATION/PERMIT PLUMBINGMECHANICAL
PERMIT NO.
DIVISION TIFICATION i 27778SS: SANITARY NO. APPLICATIONSUBMITTALDATEI/ UNIT# LOT» ({667'3I` PHONE: CONTR G 1t'S NAME: - rte- LIC NO:S ^ ( !Y/by N/C CONTROLk
EER: ❑wT1 r/er
—2—Y6
• Gkl
CONTACT; PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLDG PLUMB MECHmat ;&.. ❑
LICENSEDCONTRACTOR'SDECLARATION pppLIANCES-RESIDENTIAL I�
1400 Thereby affirmthatl amlicenudinss and rofesions Coder and mmecense with JOB CEIp'f01�
1400 Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS IV{��
0 U.5.. full force and effect.
FZ pUj License Class Lt..If L• a UP TO 200 AMPS
y M. Date - Gontntr�S 6 201-HIM AMPS S ry aJ a l•V
1"vt'z RC TE ECLARATION OVER 1600AMPS
O.O,n n $O FS FLOry M S/gQ.FT.
001IL�I.----....G l understand my plass Il be pu rc me r`/1�V rN`Jalw D
SIGNS ELECTRICAL
q'Y Liwnses Professional /
y��4J rK DER DECLARATION SPECIAL CIRCUIT/MISC.
XOyF I hereby offr am exempt from the Carlomme,License Law for the
W 3 5 to following r t.(Section]031.5,Business and Professions Code:Any city.,,.only TEMP.METER OR POLE INST.
�z which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
ty G p that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
a p 9(commencing with Section]000)of Division Smith,Business and Professions Code) SWIMMING POOL ELECTRIC yYVALUATION or that he is esempnherefrom and the basis for the alleged exemption.Any violation of
Fe ¢ Section]031.5 by any applicant for a permit subject,the applicant m a civil penalty of OUTLETS-SWITCHES-FIXTURES 2
2 14 nm more than III 1'o hundms dollars($360).
❑ Lueownernftheproperty,ormyemployemwithwagesastheirsolecompensation, NEW RESIDENTIALELECTR __SQ.FT. STORIES TVPE CONSTRUCTION
L will do thework,and the structure isnoclatended croffered nwile(Sm.7M,Business
and Professions Cada The Connactor',License Law does not apply to an owner of
proptmy whobuildsorimproves thereon,and who does such workhimselford ough his
wnemployees.provided Net such improvemenmme not intended or offered for sale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the Owner-
builder will have the harden of proving that he did not build or improve for purpose of r�
sale.).
❑ I,as owner ofthe property,am exclusively contracting with licensedconuactmm QTY. PLUMBING PERMIT FEE FLOODZONE APN
onsomat tae project(Sec.7044,Business end Po fission Code)The Contractor's
License Lawdoesnmt PPlymanownerofproperywhobuildsmimprovesthereon,and PERMIT ISSUANCE
who contracts far such projects with a tomaeamKs)licensed fa m arm to the Cm natmrs
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this as. BACK FLOW PROTECT.DEVICE OUTSID EES
Owner Date SANITARY Y_N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOG OOP, ,GOND. RECEIPT If
I herebyaffirm that l have a cerificate of consent to self-itreure,o SCHOOL TAX YN
rncertificme of P
orkers'Compensation Insurance or a cenhied copy thereof(Sec.3800,Lab C.)which FIXTURES- TRAP RECEIPT#
PARK ME Y
covers all employee's under this permit.
Policy# GAS-EA YSTEM-IINC.40 Its RECEIPT#
BUILDING DIVISION ES
Company
❑ Certified copy is hGAS A.SYSTF.M-
ereby fumished. - OVER4(EA) PLANCHECK FE6
❑ Certified a.,is Bled with the city inspection division. EAM/INDUSTRL STEINTER PPOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE P SOILS FEE
COMPENSATION INSURANCE
(Thissecrion need nm be completed ifthepermit is for one hundred colla 00) SEWER- ST RM OFT.
or less.) ENERGY FEE
I certify that in the performance ofthe work forwhich this permit is'suee,Ishall WATER T W/VENT
of employ any Person in any manner so as to became subject to a Workers' PAID
7-. Compensation Lowsof California. Date W STEM/T A G to Receipt#
Applicant
z 0 NOTTCF.TO APPLICANT:If,after making thisCmificete of Exemption,yo htuld RE$IDENTI MB. SQ.FT.ust TOTAL:
lZlbecame eubJecnt Ota Workeie Compematlon provisions of the Labor Cade,yt
••"�--�� Ij forthwith comply with such provisions onhis permit shell he deemed revokes. BUILDI
F. r
1460., z
CONSTRUCTION LENDINC AGENCY SEISMIC FEE
I hereby affirm that them is construction lending agency for the performance of
V 0 the work for which this permit is issued(Sec.3097,Civ,CJ TO v ELECTRIC FEE
w tr Lendu's Name
O L) Lenders Address Q MEC NICAL PERMIT FEE PLUMBING E
W1 certify that I have read this application aM state that he above information is
corecu I.,.to comply withal)city and county ordiaances mad state laws relating to MMISS NCE MECHANIC LFEE
rn auildimmentioedpmand herebyaection purposes,
Ives ofthiscity tocnter upon the
L) z above-mentioned pcvtyfoeinspection keep hum. ALTER OR ADD TO MECU. CONSTRUCTION TA
(We.)agree to sev Indemnify and keep harmless the City of Cupenino against
liabilities,judgm ,co so maylnanywayaccr agwr said City AIR HANDLING UNIT
(TO 10,000 CPM)
consequence flat ung spetmlt.
AIR HANDLING UNIT(OVER 10,0)0 CFM) r�
gnawre of Infractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 160,1400 BTU) Oma Receipt
Will the applicant or future building occupant store or handle hazardous ma amd as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOOR00 BTU) TO L:
Code,Section 25532(a)9 '
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will lheapplicant orfufure building occupant use equipmentordeviceswhichemif
BOILER-COMP(311P OR 100,600 BTU S A DAT
rsardoee air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 1/YI(�(][la795
❑Ye11s No NEW RESIDENTIAL MECH. SQ.FT. LIAR a
1 have read the hazardous material,requirements under Chapter 6.95 of the CI I Y yr VUreN i IIVU
California Health&Safety Cade,Sections 25505,25533 and 25534. I understand that -
if the building does oat currently have a terata,that it is my responsibility to notify the
oolot of the maireme is which most he m t prior to issuance of a Certi,r m of
Occupancy.
Owner or authomz dage t Data
TOTAL: ISSUED BY:
OFFICE