27876 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUIL G;-KLFC'1'RI,AI. PCRMI'I NO.
CITY OF CUPERTINO APPLICATION/PERMTP PLUMBING.MECHAMCAL n O C
BUILDING DIVISION BUDDING PROJECT 1DEN-1'IFICA9'[ON L O U
BUILD2NGADDRESS: SANITARY NO, APFI.ICATION SUBMITTAL DATE
OWNERS NAME: a DPIre—.& �ifi C�RACIOR'S NAME: L(ylN LIC NO: �l
", Z [� .5 / C bi CONTROL#
4,IRC IITECT/IiNGINEER: LIC NO: ADDRESS: J ❑
coNTACI: PHONE BUILDING PERMIT INFO
^] Q'I'Y. ELECTRIC PERMIT FGE
PERMIT ISSUANCE. BLDG UEC[ PLUMB MECH
❑ OA ❑ ❑
LICENSED CON'1'kACTOR:S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
0.z Ihereby affirm than l no licensed under pmvixionsofMPW9(commencingwith
( WOO Section 700d)of Division 3 ofine Business and ltofessiom Code,andmylianseisin PANELS
Fj� fall b-Z U,coseeandercect.
licenac Caner LION UP TO 200 AMPS
m?y Dutc Comenctor 201-1100 AMPS
,SNZ ARCHI'I'FCI'S DECLARATION OVER I000AMPS SQ.FT,FLOOR AREA S/SQ.FT.
O Z—n I oodemmnd my plana shall M toed es p.hire recan4.
F❑b'm SIGNS ELECT RICAL
QySJ L¢maeJ liofnnonal
KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUH'/MISC.
x c,Kw 1 hereby nffim that 1 em exempt from the Contractor's License taw for the
¢1'3 Y.y ❑Jlnwing rwxon.(Scnion)W1.5.BeAre,s seal Profresions Code An,iitymcommy TEMP.METER OR POLE,INSP.
F E:NOJ which requires a permit to construct,after,improve,demolish,or repair any simulate,
wnQ7 prior to its issuance,alto requires the applicant for such Permit flea signed statement POWER DEVICES
'y <Ca that be is licensed panuum hot he provisions of the Conoueors License Law(Chapter
a o4 9(eommcncing with Seaton 700001 Division 3 of the Ntaincas and Pmfesaiona Code) SWIMMING POOL ELECT'RIC VALUATION
W—y or that he is exempt therefrom and the huffs lot the alleged exemption.Any violation of OUTLLTSSWITCHES-
F Z Q Section]031.5 by any applicant for a permit subjects the applicant to a civil pen -
penalty of FIXTURES
not more man f vc hundred dollars($500)_ NE W RI?SIUEN'Tlnl.ELECTR _SQ.FT.
yy� I,uvownerafthc n
Fm ❑ pngc y,nrmyemployces with wagevntheiruolecompen.amian, STORIES TYPE CONSTRUCT ION
6 moi— will Jom<work.andtheUm Cr trmm,Liceese las.doss.,apply I.sor.Business
aaJ cry whPrafeslo
Cedc:The Contractors nd who law deer not apply tort owner 9f
own Om whnes,pmlds or impnrvwat chcrcoo,and who am not
work himslRu through his
ser,thew,ping or improvement himprrvld witmrtne ear000mpltended or 'fered for Elseow.IL OCCGROUP RES.UNITS
hnwcvea the building Orenfpis sold within one mem of companion,me owner- '
builder will have the burden 9f proving that he did wt build or improve for purpose of
we.).
❑ Lax the pryethe t(See.70U$, usinesv and Profetiions Cdc:)TJconmacmnam QTY, PLUMBING PERMIT FE FLOOD ZONE qPN
mmwn the pm rax(Sea m)44,Business and Professions Mane Cade:)The Contrmmnd PERMIT'ISSUANCE
License Iawdocs notapplytoanlhserofphoperywhnsedadsirr mprovhe Ccomseand
wM1tine La<txfnreuch prnjcnswithecnntmcmr(n)IiccnscJ pumm�unthe Commcmr'a ALTIiR-DRAIN&VENT-WATER PA
Llcmtre Law. EPA) FEE SUMMARY
❑ I am exempt under Stt. B&P C for thin tenon OUTSIDE IEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dam DRAINS-I REClill'1'#
_ WORKMAN COMPENSATION DECLARATION FLOOR,ROOF,AREA.COND. SCHOOLTAX Y N
III ❑ 1hereby affirm that l have acenifcateofconsent toself-insum.macenificamof RECEP`I'#
Wnrkers'Campensuuon lmurance oraceniEal copy mertogSec.3800,Lab C.)which FIXTURES-PER TRAP PARK PER Y N
coscra all employee's under this pernit GAS-lin.SYSTI3M-0 INCA OUTLETS RECEIPT N
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Gasified copy is rata with me city inxpuminn Jivisimt. GREASIVINDUS I'RI.WASTE INTERCI7I11 OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tlim emina need not be,mmpincd ifthe penniGsharne humboddollars(51(X)) SEWER-SANITARY-STORM EA.20OFC ENERGY FEE
orlave.)
Easily that in thelcrformmnce ofIhcw.,k fo,which thispermit is issued,Is hall WATER HEATER W/VEXT/ELECIR
I not employ any person in any reamer so as m become subject to the Workers' PAID
z Compensation Lawsof Culifnmiu. Date WATER SYSTHAVIREATIN( Dae Receipt M
Applicant
zO NOT ICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIALPLEM SQ.FT. TOTAL:
f" rq become subject to the Workers Compensation provisions of the Labor Code,you must
fonhw'nh comply with such provisions orrhk permit shall he deemed revoked. BUILDING FEE
00.. ❑ CONSTRUC EON LENDING AGENCY SEISMIC FEB
Z) Z I hereby affirm that Ism is a ctmewetion lending agency for the performance of
U O the work for wach this Permit is issued(See.3097,Civ.C.) TOTAh. ELECTRIC 103E
Leader',Name
0 U Lemlers Address QTY. MECH . ICAL PERMIT FEE
PLUMBING FIE
} U I cenify that I have read this application and state that the above information is MECHANICAL FEE
cmt. I agree to comply with all city uod mum,ordinaneenuulstatc Iowa mlaingm I'IiRMI'1'ISSUA '13
building construction.and hereby aumnn¢rtptescominves udhis city tocater upon the CONSTRUCTION TAX
U 'Z ahrvomeadminal property for inspection purposes. ALTER OR A/.TO MECH.
(We)agree to save.indemnify and limp harmless the City of Cuperino against
liubil'nins,judgments.coasund expOmms which mayln any wa "aa uvt addCoy AIR HAN INC ON]'I'(TO 10 FM)
inconsequence of the granting ofthisprnmit. ill V�
AIR H .DUNG UNIT( .000 CFM)
Signatum of Applicant/Con um E AUS'1'U00D(W/DUC'1
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TTKkJWPTU) Date Receipt N
Will the applicant or future building occupied short or handle hazardous material
as dcfncd by the CuPemm,Municipal Cmlc.Chaper 9.12,unJ the HcAth and Sulny HEATING.U ,R 1 W, T ) L:
Core,Station 25532p)P
❑Yea ❑No VEM'ILATIO M
NGLE RESIDE
,000 BTU) ISSUANCE DATF�
Will mmcupplicaor fwurcbuilUingom mm
ccupuacquipmcnrdcviccx whichemBOILER-COMP LEHP OR 1!10
at i T
lim"Oous air contaminants as defined by the Bay Arca Air Quality Management LER-COMP(OVER I00l"IT n/��
i Disain'!
❑Yes 11 No NEW 'SIDPNTIAL MECH. S .FT. AI
I have read be harurtlous materials acquirements under Chapter 6.95 of the Cp 1, (.4
O 19gS
California Health&Safety Coda Sections 25505,25533 and 25534.I understand that L/r LV
if the building docs not currently have a tenant,that it is my responsibility to notify the rCK� rr.
uupant of the requammnu which must M met prior to issuance of a Ccrtificam of
occupancy.
Owner or umhorimd agent Date TOTAL: ISSUED BY:
OFFICE