28039 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' '- "' PERMITNO.
APPLICATION/PERMIT PLUMBING-MRCHANICAL /� O O/g /1
BUILDING DIVISION BUILDING PROJECT]DENT ''ICAI]ON G o 3 BVI
BUILDING ADDRGS/.q''� SANITARY NO. AAP I
^PLICATIONSUBMTALDAT
so�O UNIT# LOT o �
OWN- SN CONTRACT_ ON'S NAM' LIC NO:
/`I'YAA• Jh^'\ NIC CONTROL#
1119 ARIIITFLT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMRISS ❑ ❑ }�f El
LICENSED CONTRACT'OR'S DECLARATION pppL1ANCES-RESIDENTIAL L�+
pmZ lherebyalfrmthal lamlicenmdunderprovisionsof Chapter9(commencingwi JOB DESCRIPTION
pJ00 Section]000)of Division3of the Business and Prvfessiona Code,and myli in PANELS P1� 1 •��
FZ, full force and effect.
LiccnmClas Lich UP TO 200 AMPS
w=y Date Contractor 201-1(X10 AMPS
ZOyZ ARCHTEDECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.IT
—
a,-
07—a 1 understand my plans sail be used as public records.
SIGNS ELECTRICAL
N< Licensed ProRssiowl
ac OWNER-BUILDER DECLARATI/sd
SPECIAL CIRCUIT/MISC.
NyU 1 hereby affirm that I am exempt from the Contratense Law for the
N
3 a y following reason.(Section)031.5.Business and Profession :Any city or county Nfp OR POLE 1 T.
Oy; which requires a permit to construct,alter,improve,demorepair any a On
.� }5 prior um its issuance.also requires the applicant for such perleasigardsta{ement EDW V ES
O py� thus her,licensed puraram.m the pro,nu ma of the Contraccerm Law( apmr
d ExC{y 9(commencing with Section 7")of Division 3 of the Basd"'d mons ode) ' CRIC VALUATION
W_y or that he is exempt therefrom and the basis for the alleged eon.Any 'oT fOlifl. WITCHES-EI RES )
tZ} Section]031.5 byany applicant far a permit mbjectsthe ar ma civil penn ¢rnfvehundreddollnrs(SSW).ad ❑nl,asowneroftheproperty,ormyemployecswithwagersolecrsr!! NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTIOb
will do the work,and tacstmcmse is not imandedorofferedf (Sec.VB44,Bum.a
and Professions CMT.The Commaors License Law due. not apply m an owner of
propeny whobuiWsnrimpnwes thereon,and ware Jres such irk himselfor through his OCC GROUT' RES.UNI TS
sun employces,pmvidaJ that inch improvements ate notim dedoroffcrcd(,role.IL /
however,the building or It
cmemis soldwiNitineyear (completion,theown TOTAL:
builder will have the burden of proving that he did rot build o 'mprove for of
sale).
❑ 1,usownerofthe property,um exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
onvmet the project(Sec.7814,Business and Professions Com)The Corrosion's PERMIT ISSUANCE
License Law does not apply m an ow mer of property who bis ilda or improvea thereon,and
License Loss
for such projects with afantractorts)licensed pursuantmthe Convacmr's ALTER-DRAIN&VENT WATER(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. II&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dae COND
AREA,, . RECEIPT'#
•
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL,TAX Y N
C] m I hereby affirthat l have a cenificum ofcomsenuo selbirome,nr a eenificae FIXTURES RECEIPT#
%TURES-PER TRAP
Workces'CompensuJun lmurvnce oraemlficJ copy lh<rcnf(Sec.3gW,Lub CJ which PARK FEE YN
RECF.IPf#
Cover,all employee's under this permit GAS-EA.SYSTEM-1 WC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTCM-OVER 4(EA) PLANCHECK FEE
❑ Climbed copy is hereby famished.
❑ Cer ified copy is film with the city inspection division. ORE- SMNDUSTRL WASTE INTERCEPTOR GRADING TLE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM HA.]WFT. ENERGY FEE
or less.)
I certify that in the perform.,ifthe work for which this permit is issued,Idurt WATER HEATER W/VENT/ELECIR
not employ any person in any mama an,u to become subject to the Workers' PAID
Comps,mation la ss of Califomia. Dare WATER SYSTEM/fRFATING Date Receipt#
Q z Applicant
z 0 NOT ICE TO APPLICANT:If,after making this Certificate of Exemption.ycashould NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
E•-' rn become subject to the Workers Compensation marrium of the Labor Cade,you mum
� ? forthwith comply with such provisions or this permit shell k dinned revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 hereby affmn that them is a contraction lending agency for the perfomance of
the work for Permit which this peit is issued(Sec.309],Civ.C.) ELECTRIC FEE
QU 0 Lenders Name PLUMBING FEE
U Lender's Address QTY. MECHANICAL PERMIT FEE
L.) I candy that I have read this application and stare that the above information is
Lijcorrect,I agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE MECHANICAL FEE
I" building construction,and hereby authomo reprruntafveso(thin city menter upon the CONSTRUCTION TAX
U Z above-mentioned property for in. tion purposes. AUIER OR ADD TO MECN.
(We)ago m save,Inn or ant cep harmless the City of Cupcniro against
livbilitmajudg core n. hich may irony wayaccny against. ll City AIR HANDLING UNIT(TO IU,OWCF.M)
in covequen o th o t permit
AIR HANDLING UNIT(OVER IQOW CFM)
abirca ill frac If, OFT EXI IAUST HOOD(W/DULT) PAID
HAZARDOUS MATERIALS CLOSURE
HEATING UNIT(TO 1,010.000,BTU) Date Receipt#
Will the irlithe Cuaernismun or Munire cipal
Code.ng #aprons,.aaMlehazalth and Safely
I(EATING UNIT(OVER I W,WU BTU) TOTAL:
as defined by the Cupertino Municipal CMe,Chapter 9.12,and the Ileallh end Safey
Crxlc,Sccli 25532(a)7
11Yes ❑No VENTILATION PAN(SINGLE RESID)
❑
ISSUANCE DATE
Will theapplicumorfumrcbuildingoccupanmxeyvipmenwrdevico whichemit BOILER-COMP(JHP OR IW,B00 BTU)
ba'eardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District]
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the haardous materials requirements under Chapter 6.95 of the
California Hcallh&Safety Curt.Sections 25505,25533 and 25534. 1 unducsamd thus
Ifthe building does not comemly have.tenant,that it is myma,umbilo, ,notify the
occupant of the requirements which must be met prior to issuance side Cenificare of C��t
Occupancy. � e19
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE