27785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO AUH.I57NT. I:F,CTIFECAL PERMITNO. ^ .p 's
APPLICATION/PERMIT PLUMB N MECHANICAL L 1/ lyJ(
BUILDING DIVISION BUILDING PROJECT'IDENTIF'ICA•I']ON
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT# � �
OwN RS NAME: PHONE: CO CTOR'S MG: LIC NO:
/ - �/ C . IN CONTROL#
ARCH]FECT/ENGINF,ER: LIC NO: ADDRESS
�IS152ES 74M
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BIL EL PL IMB MECH
PERMITISSUANCE ❑
LICENSED CONTRACTOR'SionsDECLARATION APPLIANCES-RESIDENTIAL SC 1 III.•r�
GCZ Ihcmlry of Di Nati arm 3 ofth Business and
PProvrofessions
Code,
mmeneing with y� v`
�i100 Section]00(Bof Divivion3afthe Business end Prolcssions Cade,end my license is in PANELS \\
aUF full force it effect
stir6 VVI Lucmn, 2WAMM 91.11-41%
Lic.#c444� I I &
hm- 201TO1000 AMPS ���/
ComosZOy? ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
07-C 1 understood my plans shall M used as public muc rds. f
F_ W SIGNS ELECTRICAL
Licensed Professional
�p;CG OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
XyU 1 hereby off rte that I am exempt from the Contractor's License Law fertile:
W 9a m following examen.(Son 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O5 which requires apermit mennalmct,alter,improve,demolish,or repair any structure
Y:j: Prior to its issuance,also acquires the applicant(orsuch permit to file assigned statement POWER DEVICES
WK 00 that he is Iiceas of pursuant m the provisions of the Commerce,License Law(Chapter
a o� 9(emnmencing with Section70mB)of Division 3 of the Business and Professime,Cade) SWIMMING POOL ELECTRIC VALUATION
m-w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F-Z Q Section 7031.5 by any applicant for C permit subjects the applicant Wer civil penalty of OUTLETS-SWITCHES-FIXTURES II w -aaaaa
not..to thnn live hundred dollars($500). NEW RESID ALPI.ECTIt _SQ.PT.
CRo ❑ 1.mownerofNepmpWy,ormyemploy«swiNwagesaslbeirulecomperssadon, STORIES TYPE CONSTRUCTION
will do the work,and the swcture isnot intended mothered fessle(Sec.]0g4,nosiness
and Pmfessiom Cale:The Contractor's License Law does not apply to an owner of
Property who huilds or improves themun,and who docs such work himself m through his
inviie.oploycei,p imundedoroffered I..in .If. • - OCCGROUP RES.UNITS
however.the built ing or impmvemcnt is mid within one yearofcomplction,the oumer -
beildcr will have the burden of proving that he did not build in improve for purpose of
sols). .
❑ Las owncrofthc PmPertY•tort exdusivdyconvacting wish licensed contmcwrsto QTYPL RING IT FEE FLOOD ZONE APN
onsvuct the project(Sec.7044.Business and Professions Code:)The Committers
License Law does nut apply tosnowncroflofory who builds orimprnves thereon.and PERMIT ISSUANCE
who contracts forsuch pmj«m with acontmemr(s)Iicerud pars..... the Convectors ALTER-DRAIN&VENT- (EA)
License law. WAl FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this toren BACK FLOW PROTECT.DEVICE a UTSI s FEF_S
SANITARY YN
Owner ON'-. p .— DRAINS='FLObk;7F6TFYAREA?CONT.•-='m't RF.CEIPTa
WORKMAN COMPENSATION DECLARATION'-. SCHOOLTAX YN
❑ Thereby affirm thatlhaveacenificew ofconunno self-tosser(,m ircertificateof FIXTURES-PER TRAP RECHIPfp
Workers'Compensmion Insurance or a certified copy themof(Set.3800,Lab C.) I PARK FEE Y N
eovm all employ«1 am.Nis penniL G a E.�.SY M I .4 RHCIiI p
Policy n - BUILDING DIVI ON FEES
Company EqD��
❑ Certified copy is hereby famished. GAS;VY PLANCHECK FEE
❑ Certified copy is fled with Ne city inspection division. GR' NO LW NTfRCEPfOR GRADING FE
CERTIFlCATE OF EXEMPTION FROM WORKERS' �T Gft APLj
I I 'Z SOILS FEE
COMPENSATION INSURANCE 'i
or less ,s section n«dtmt becomplewdiflhe pemdtu foronehunrdreddoll tatty) SEWER-SANITARY-STORM EA.21k; 1 EN
I certify that in the performance of the work for which Nis permit l55sseargi ililn ....WA1Tdl AEA79YW{VENT/ELECfRi
not employ any person in any mmm«u as w become subject to he Worker%
z Compensation Lnws of California. Dew /I
WATER SYSTEMREATING PAID ole Receipt#
APPlicam
z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.IT Del
pttTOTAL
become sudden m the Worker's Compensation previsions of the Labor Code,you must
04 - forthwith comply with such provisions or Nis Permit shall be deemed invoked. BUILD] GFEE
ped, Q CONSTRUCTION LENDING AGENCY SEIS. FEE
Z 1 hereby affirm that them is a construction lending agency per the perfommnce of
V O the work for which this permit is issued(So.NP7,Civ.C.) ELECTRI dlU. ""ICooler's Name U Lender's Acidness QTY.jAIRI'MiNDLING
ANICAL PERMIT FEE PLUMBING 'E i1
I certify that 1 have mad this application and state that the above information is MECHANICAL -E
OW. correct l agree us comply with all city and county ordinances and scam laws existed,to CE
F-' V) buildingcom uction,told hereby authorise repmesnmtivesofthis city m enter upon me
L.) Z above-mentioned property for inspection purposes. TO MECH. CONSTRUCTION' X
(We)agree m save,indemnify andJJ✓✓ee��������leas the City of Cupertino against
inromtotjudPrlf�n, sand eapen hicyFnay ins way ueerue Cgaiaasaid City ON]]'(TO IQOfX)CFM)
ennscquc ft emingoft i44pe ((
ars AIR HANDLING UNIT(OVER 10.000 CFM)
zu,
EXHAUST HOOD(W/DUCT) PAID
HAZARDO MATERIALS DISCLOSURE, HEATING UNIT(TO 100,0110 BTU) Date Reiptp
ll the applicantdeforumHealthdio he Copcnino Municipal Coda Chapter 9.12,enJ the Health and Safety HEATING UNIT(OVER IW,000 RTU) OTAL:
Code.Section 25532(C)'t
❑yes 0N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 1110,000 BTU) ISSUANCE IE
Will for co icantorfuws huilding by
BayA .Airl oath Management P A i D
indicate,yr contaminants as define]by the Bay Arta Air Quality Management BOILER-COMP(OVER TO."uicl]
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.Er. sr��
I have rmd the hazmdons materials requirements under Chapter 6.95 of the A 1(�(�[
California Health&Safety Code,Sections 25505.25533 and 25534. I understand that /mT IJa7a7
if the building]nes not currently have a tenant.that it is my responsibility to notify the C�11 GurEM
ccupnnt of the reyuircnwnts which must be mel prior to issuance of a Cedifcmc of OF
Occupancy
Owner or uothurved agent Dow TOTAL: ISSUED BY:
OFFIC
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