27405 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO V.Up-ELKU A" PI3RMIT NO. 0
APPLICATION/PERMIT PLUMBING-MF,CHANICAL
BUILDING DIVISIONBUILDING PROJECT IDENTIFICA1[ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMRTALDATE
UNIT# �� I,O'1'N
O A E: Pf10 ORS 4ME: I O:
NIC COMROLp
RC1111F.CT GINEER: IAC NO: A ❑
�i
CONTACT: _ PHONE: QTY ELFeCFRIC PERMIT FEE BUILDING PERMIT INFO
-�� - FILM ELECT P Md MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ihereby affirm arm l am licemed under provisionsofChapter9(commencing with
W C O Section)000)of Division 3 of the Business and Professi Code,end my license is in PANELS
aVF full fame and
FZm Lianx Class�d� UP TO 200 AMPS
ce'N Date Conwcmr 201-1000 AMPS
Zoo, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.MOOR AREA S/SQ.IT.
Z o o O I understand my plans Shull be used as public recarJr.
F ec G� SIGNS ELECTRICAL
QYE,� LionxJ Professional
did aQ OWNER-BUILDER DECLARATION SPECIALCIRCUHyMISC.
X O u- 1 hereby affirm that I ten exempt frmo the Contractor's License Law for the
W3ain following ouxm.(Settinn'l03 1.5,Business and Pmfesions Cade:Any city or mmnry TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any swemrt
priorto its issuance,also requires the applicant forsuch permit to file a signed statement POWER DEVICES
,K O o that he is licensed pursuant m the provisions of the Commmots License Lew(Chapter
a'goLL 9(contracted.,with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
XW_„, or chat he is exempt therefrom and the basis for the alleged exemption.Any violation of DUTLEr$-SWRCHFS-FIXTl1RES
F Z_¢ Section 7031.5 by any applicant for a Permit subjects the applicant to a civil perally of
,adS� not mate than five hundred dollars(5500).
, , Y 8 p , NEW RESIDTALMEM _SQ.FT.
STORIES TVPIi CONSTRUCTION
a3=a will Pmessiones and the he m iti dam's License
Law
dos not aply t 044,Business
and Pmfessions Cute:The Contodern,License Law does not apply lf rt owner iof
s
own can whobuildsserimproveslthat chemen,andwhodocssuchnark oroffe mthrough his
employeb,pmvidrr improve impis sold within
not earmdmpletiod forthe ow. r. OCC.GROUP RES.UNITS
however,the building orimprovementissoldwithinoneyear or improve
omm efor the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑ 1.as the project
(Srope7M,Business
sivelyrentnning s Codd)The Contractors
tors QTY. PLUMBING PERMIT FEE FLOOD ZONE ppN
conurva the project ISec.)014,Business cad Professions Cade)The Contractors
License Law does not apply lannownermpnsperty whobuilds orimprove thereon,and PERMIT ISSUANCE
who contracts for such pmjects with acontractons)licensed pursuanuo the Coundictols ALTER PA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACK MOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
•
Owner Date DRAINS-MOOR,ROOF,AREA,COND,
ElRLC[IPTM cu WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
Ihemofficiation affirthetlhaveecenifiw¢of comate muinsu
t(- m,orefifi
cercem of FTXTURFS-PER TRAP RECEIPT-
Workers'CompenwtionlnsurenceoraceniEW copy them.f(So.3800,IabCJwhich PARK FEE YN
a all GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT N
Ismicy M BUILDING DIVISION FEES
Company
❑ Ce.
Company
t c by W. GAS-EA.SYSTEM-OVER4 PA) PLANCHECKITE
❑ CcniOcd copyis filM wecity inspationdivi' n. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICAT33 OF EXEMPTIO OM WORKERS'
COMPENSCE GREASETRAP SOILS FEE
ATIO SU N
(This section nod not be comple thepermit' foronchundrMdollr� i ) SEWER-SANITARY-STORM EA.2IX)FT. ENERGY FEG
I certify that in the pert. ceofth or to w c this penniti is ap.1$al WATER HEATER W/VENT/ELECTR
nm employ any parr any maturer oma s jot . WVeef�� PAID
Z
Compendium ws of Crdifund Date WATERSYSTEM/IREA'rING Dam ReceiptM
Apdri m:
z0 NOTIICE'r0 PPI CA :ILor Ic gt ' aLIZto0 Ex mpti ,you should NEWRESIDENI'IALPLMb. SQ.FT, TOTAL:
F" fA become suit v to t n 9 , of Ne La ode,you must
foMwith co ly with so er tsbnx or a vt tImllbe dic rtvoked. BUILDING FEE
UA Q CONS vJCTIONLCNI INGAG Y SEISM IC FEE
z I he by Erm tM1m theretr a emarruction lendln enc,for the performance of
U O 'he work for w ch this Permit is issued(So.309], v.C.) T ELECTRIC FEE
Leader's Name
0O U Leaders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that have read this applic on and state that the above in1'ommation it
Fr-' OW. cermet. lugro to co ly with ell cit county ordinances and added laws relating to PERMIT ISSUANCE MECHANICAL FEE
_ buihli,corearmuon, re mittmprteanddGvex m doicitywemeruponth<
U Z abdveancelioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(Wc)agree ns save,indemnify send keep M1a less dm City of Cupertino againm
liahilitics,jud osesandcx nanywt,owerue gairestaai City AIR HANDLING UNIT(TO 10,000 CFM)
no to c e gr g di
ANDLINGUNIT(OVER IA000CFM)
gi
Signature ul licat/Comm or Date EXHAUST'HOOD(W/DUCT)
PAID
HAZARDOUS MAgoce.pSDISCLOSURE HEATING UNIT(TO 100,000 BTU) Date R<ttiptp
Will the applicant Catania.
ia.ture Munbuildingoccupantstore or handle hHealth usmaterial
as refined by t25 Cupertino Municip:J Coec,Chapter 9.12,send the Health send gaiety HEATING UNIT(OVER I W.000 BTU) 'TOTAL:
Coda,Section 25532(x)'!
❑Ycx 0N VENTILATION FAN(SINGLE RESID)
Will theapplicnmrnfumrebuilding occupant uuequipment ordevices which emit BOILER-COMP(3HPOR 100.0dDBiV) ISSUANCE DATE
hooDisurdoux air ammminunts us defined by the Bay Areu Air Quality ManagementBOILER-COMP(OVER 1 W,WO BTU) 40
District? 4'1
❑Yes ❑No NEW RESIDENTIAL MECH. 'co FTp 'b.
I have read the haxardnus mamtlals requiomema under Chapter ��6.95 of the 41 a t�
California Health Come,Sections 255115,25533 and 25534. 1undendandthm
if the building does not currently have a tenant,that it is my msponsibility to notify the
occupant of the mquircments which must he met prim to issuance of a Certificate of h
Orwpmtcy.
owners amnanrm agene Dme
TOTAL: ISSUED BY:
OFFICE