27937 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PR .ECT'
CITY OF
CUPFRTINO 11.1L.1Ni:..l..CLTALCXI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27937
R N( 11 1'IC
BUILDING ADDRESS: SANITARY NO. APPLICAT11ON•SUBMITIAALL�DA9E
Ub?ITN Dal# L{�
OW RS NAME: - PHONE: CONTRACTOR'S NAME: LIC NO:
/7�i J_ a/Z N/C CONTROLM
•ARCH�ISTECf/FNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
LDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El
LICFMSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby ffirm that I am licensed under fCTat 9(commencin th _ TOB DESCRIPTION
1402oll Ya pmviolonsn per gwi f\In/rr►/"�ky_`Y•r-�
Y100 Seninf❑ivisionJof the Business and Rsirn
vfess Code,and my licrnuia in PANELS
FFA—,V full fnrectce and andeef(ecL UP TO 200 AMPS 1 •1
fFF License Clus Lin,p \�J
y?
Dale Contractor 201-1 I AMPS SQ.PC FLOOR AREA $/SQ,FT.
ZOr'n'4 iaa h used
OVER DECLARATION OVER ItMp AMPS
O Z—OO I understand my plans shall ed az public rea
cnts.
f,�'e�-W SIGNS ELECTRICAL
Licensed Professional
C y6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO dU 1 hemby affirm that I am exempt Tran Ne Contmcto'.License Law for the
W 3 LL y following mason.(Section 7031.5.Business and Professions Cale:My city or county TEMP.MBfE0.OR POLE MST.
F-� which requires a permit to construct,otter,improve,demolish,or rcpsir any structure
WYE prior to its issuance.also require the applicant for such permit to file a signed statement POWER DEVICES
CC a O that he is licensed purxunnt to the provisions of the Commeto,'s License Law(Chapter
a Pj Wo�i' 9(cammencing with Section 7000)0 Division Sof the Bit .., it Pmfessimas Cade) SWIMMING POOLELECIRIC VALUATION
WM,o or that he is exempt herefrom sold the basis for the alleged exemption.My violation of OUTLETS-SWITCHES-FlXTURES
Z G Section 7031.5 by any applicant for a Acs nt olbjecis the applicant to o civil penalty of «�
W not more than five hundred dollars(S50E. NEWRESIDENTIALELECIR S .IT.
K� ❑ oche arms,
inummeswilhwegeasstheiSec.7um,Business Q STORIES TYPE CONSTRUCTION
a will dmbewons andthe swmoreiactor's Lnense-offieTedLaw
forside s not
To ano Business
and Professions Code:The Contractor's License Lew dura not apply m an owner of
Emptily
mployb,pmyir ffiaissthempmvem ts=nodomi ouch tintmdkhimselfartivoue.If. OCC.GROUP RES.UNGS
wncv,.Th buiprovini Natsuchimproveman¢seenot er.frmoffere.forsale.If.
however,Nebuildingorimprovementishathwithinoneyewo improve
builder will have the burden of proving that he did nm build or improve for puryou of TOTAL:
'ale.).
11I,ece
owner nfthe protY,wneadusivdnN
y contracting contractors QTY, PLUMBING PERMIT FEE FLOOD ZONL> APN
construct the project(Sec.7044,Business and Professions Code:)The Commactor's
License Law does not applyto an ownerofpropeny whobuildsorimprovesthermn,and PERMIT ISSUANCE
who contracts forsuch projects with acontmctos(s)licensed pursuant tnthe Convectors ALTER-DRAIN&VENT-WATER pA
License 1sw. ( ) FEE SUMMARY
❑ 1 om exempt under Sec. ,B&P C for this msson BACK FLOW PROTECT.DEVICE TS L
SANITARY Y_N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF, CONIC.WORKMAN COMPENSATION of mNDECLARATION SCHOOL TAX Y N_
❑ enc Co affirm that Ib comave e oriventenf copy Themd(Sakent to ceure,ar aretifs am ofwhich FlXTURES-PER TRAP RF.CEIPfN
Workers'Compensmion lmumnce orecertifedcopy Nercof(Sre.Jg00,IsbCJwhicb PARK FEE YN
coven all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy N BUILDING DIVISION FEES
Campany GAS EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cor ified copy is hereby furnished.
❑ Cetillch copy is filed with Ne city inspection division. GREASPONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASL'TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted if the permit is(move hundred dolls s(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the perfasmance of the work for which This permit is issued,l shot[ WATER HEAWR W/VEITT/ELECIR
not employ any person in my,manner so as to become subject to the Worker' PAID
Compensation Tawaof California. Dam WATER SYSTINIrRp.ATING Date Receipt#
O Z Applicant
z O NOTICE TO APPLICANT:ILofret making this Certificate of Exemption,you should NEW RESIDENTIAL PLNHL SQ.FT. TOTAL:
Iecmmc subject to the Worker's Compensation provisions of floe Labor Code,you most
forthwith comply with such provisions or This Permit shall be deemed revoked. BUILDMG FEE
C3a
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affum That there is a construction lending agency fm she performance of
U O TOTAL: ELECTRIC FEE
the work for which this Izmdt is issued(Sec.3097,Civ.CJ
I2. Lenders Nome P PLUMBINGFE:
O U Lender's A..reaa QTY. MECHANICAL PERMIT FEE
I certify that I have mad this application and men that the above Informative is MECHANICAL FEE
correct.I agree to comply with all city and county cormances and state laws retailing to PERMIT ISSUANCE
I" building cimarmition,and hcrcbyamhnirem,reuntativesuf thiscity toemerupomhe CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save.indemnify end keep hwmless The City of Cupertino against
Imbilities,judgments,cost,wd expense which ma in any wry accrumgairsomil City ATR HANDLING UNIT(TO 10.001CF10)
r. ce.fthegmntingofthi mtit.
AIR HANDLING UNIT(OVER I10,000 CPM)
Signmurc Appli rm/Cunnunor r1 au EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Willtheap hernt re future building occupant sioreor handle hazardous material A
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(0)? VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
Will thmtpptic0nmrfuwre huildingoccupantuxequipmem ordevices whichemit `
BOILER-COMP(3HPOR I00,"BTU) I t)ffDATE
hat Nous air contaminants as defined by the Bay Am Air Quality Management BOILER-COMP(OVER 100,000 ITT U) �r
DisMcB $® /'-y9VC
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. //�
I have read the hbaardous materials replisemems under Chapter 6.95 of the C Li`UVJ
Q
Confucius Health&Safety Cale,Sections 25505,25533 end 25534. 1 undersand that UI-CNIt' ^
if the building tine not meatscurrently have o sober,that o is my responsibility,
suance of a to ratify the Q�
occupant of the requirements which must be mm prior to issuance of a CmiOrss of
Occupancy.
Ownermauthorizedagent TOTAL:Date ISSli DBY:
OFFICE