27496 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC I RICA L PERMITNO.
APPLICATION/PERMIT PLUMBING—MECHANICAL 2749
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BUILDING DIVISION BUILDING PROJECT IUEN'PIFICATI(IN L LTJ
BUIL GA1IDDRUUSS�:/ _ SANITARY NO. APPLICATION SUBMITfAL DATE
1 kk I V !-�L UNIT# LOT# a��
O NIiftS NAMIi: r-Po�^, PHONE: NTRACTOR'S NAME: LIC!NO: N/C CCUN9'ROL#
aRClflrECT/ENGINEER: ,V L•ICF)NO: -/ / DRESS: ❑
corvTAcr: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
BLDG ELECT PLUMB MECH
El F-1 ❑
LICENSED CONTRACTOR'S DITCLARA DON APPLIANCES-RESIDENTIAL
poll IM1ereby affirin that am lirensedunde Prookiom clasper 9(commencing with TOB DESCRIPTION
{x11q of 00 Section Dlviaon3 of the Ba,Inessand Professions Cole,and my license is in PANELS
IC U full force and effect.
Lice
y6y Damnse Clusx Lie.4 UP T 200 AMPS
Contractor 201-I"AMPS 6
8-2 ARCHITECTS DECLARATION SQ.FT.FLOOR AREA VSU FT,
O'Z—
Z O vs0 am,a" I micnd my plans shall be,used.public record,. OVER 1000 AMPS
F F-; SIGNS ELECT TICAL
Q,L�,� LlcensW Professional
C� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OW,
d1 hereby affirm Ihat 1 am exempt Bom the Connanors Lksmak Use for the
u$ati following reason.(Section 7031.5.Business and Professions Co :Any city nr cos TE ETER OR POLE INST.
Come
F"0. which requires a permit m construct.alma improve,demolish,or repair any sI art
�y�a1m-E primloilsissuence,alsu requireslM applirmfor such penniunfleasigned sr einem POWER DEVIC .
K p 0z that he is licensed pu mmout to the provisions of the Contactors License Law Chapter
a
k.22o,
9(commeneing with Section7"O..'Division 3uRhe Business and Prefers ns Code) SWIMMING Tr, ELECTR VALUATION
ty_y or that he is exempt therefrom and the basis for the alleged exemption.Any iolationof
F-Z> Section]031.5 by any applicant for a formal subjects the applicantto a a it penalty of OUTLETS-SWITCHES-FIXTURES
_
net more than five hundred dollars(S500).
CFo ❑ l,asownerof lhepmmery,nrmycmployecswith wagcsusthcirso compersminn, NGW RESIDIiNTI LELIiCfR SQ.FT. STORIES TYPE CONSTRUCTION
a3=° will do the work.and the momentum is not intended oroffcmd facade( .]OW,.asiness
and Professions Code Tire Contractors Littnac Law does not ap Y to an Owner of
Properywhobuildsorimpmventhacon,andwhodoessueh work muIfrr Wonghhis
ovoreamployces,provided thalxuch improvements are nothrend ororfcredforsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year mmpletio theowout, 'TOTAL:
builder will have the burden of playing that he did not b' nr improve for pit seat
sale.).
❑ I,asownerofthepon ny,amexclu.vivclyc meting with licensed ecoracmm to QTY. P U GING -R T FEE 1'I.O0DZONE APN
construct the project(Sea.]0,4.Business Professions Code:)The Contractors
Lirenu hwd<res not applyman ownerof npenywhobaddsorimpfovesmereon.and PER TI U CH r�
who contracts Formula projects with a co machummlicensedpursuant to the Conracmr's
License Low. A TE -DRAIN&VEMP WATER(EA FEE SUMMARY
❑ I am exempt under Sec. ,B&P C path, 417 A OW PROTTCT. EVICE OUTSIDE FEES
Owner SANITARY YN
Dam DRAT S.FLOOR,R(]O AREA,COND. RECEIPT#
WORKMAN COMPENSATION :CLAY. r SCHOOLTAX Y N_
❑ ers'Coyaffirm thnldhrance orificummf ecopy t mlf-insure.or ac are of FIXTURES-PER TRA RECEIPT#
cm,xworkers Compenarnnler this earacenirm copy the (Sec.3R1X1,Lab C.)which PARK FEE Y N
lis allemployee's under this permit GAS-EA.SYSTEM- INC.IesI TS RECEIPT'#
Policy p BUILDING DIVISION FEES
Company
❑ Ccrificd ca GAS-EA.SYSTB OV F,R 4(BA)
copy is hereby famished. BUILDING
TBE
❑ Cerlfed copy is filed with the city inspection division. GREASMNDU L WASTE INTERCEPTOR GRADING FEE
CER'I'IFICATE OF EXEMPTION FROM WORKERS' GREASETRA SOILS ME
INSURANCE.
(Thissectimnttdnolbecomplatdihhepamtitisforonchund dollars(SIOp) SEWER. ITARY-STORM F.A.200FT. ENERGY FEE
or less.)
I verify that in the performance ofthe work for which this permit is issued.I shall WATER HEATER WNENT/ELEM
nm employ any person in any manner so as m become subject m the Workers PAID
Cma,m%mmn LiOv Of Cabrmnia. Dam WATER SYSTEMIrREATENG
zz Applicant Date Receipt#
C) NOT ICE TO APPLICANT:If,after making this Cenificam of Exemption.you should NEW RESIDENTIAL PLMB. SQ,ET.
V) become subject n the Workers Compensation provisions of the Labor Code,you must TOTAL:
forthwith Comply with such previsions or this permit shall be deemed revoked.
x > BUILDING FEE
C. Q CONSTRUCTION LENDING AGENCY SEISMIC ITE
Z IM1ereby affirm That them is a construction lending agency for the performance of
U O the work for which this permit is issued(See.309].Civ,C.) L: ELECTRIC FEE
Lenders Name
U I Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE:
I certify Ihm I have mad This application and sesta that the above information is
4 cores, l agree mcomply with all city undcountynrdinanees and stale laws relatingm PERMIT ISSUANCE MECHANICAL FTE
_ N buildingconsrruclion,and hereby anchorite remmsenlatives oflhis city mender urym the
U z aMwe-mentiuncd plapmy for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,indemnify and acph less the City of Cameroun against
Its dalies,judgmems.cosFsandexpenu vMen yin wayecerueagainsT said Cit AIR HANDLING UNIT(TO 10,"CFM)
in on ex, cnce ofthe gm iing o`'s
/L� c 1A �. AIR HANDLING UNIT(OVER 10.IX0 CFM)
\ Y I
folmot err Applif /Commcwr Dae EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERI DISCLOSURE HEATING UNIT(TO 100,1100 BTU) Dam Receipt p
Will the applicant or future building eve pard store or handle hazardous malarial
us defined by the Cupeninu Municipal Code.Chapter 9.12,and the Health and Safety DEATING UNIT(OVER IM."BTU) TOTAL:
Cole,Section 25532(a)?
❑Yes 0 N VENTILATION PAN(SINGLE REBID)
Will the applicant ormarm,buifdingoccu Tutee BOILER-COME(3HP OR 1(0.10KO BTU) ISS Ij'A aE DATE
pan qea Air mrdevic Management W
aallous air conlaminens ss eefned by IM1e Bay Arca Air Quality Management BOILER-COMP(OVER IW.gO BTU)
imrictl
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.ET.
I have read'he hauNous mamriak reximmacnls under Chapter 6.95 mf the airy AN 1995
CNifnnlia I lealth&Safely CI de.Smions 25505.25533 and 25534. I understaad thin LU
if the building docs not currently have a lm tenant,that it is my responsibility minify the Na ,
occupant Of the rcyuircmm�Ls which muststle met prior issuance of a Ce y/
pay/1
rtifcam of "(,S
Occuncy. K/
Owner mr amhon kful ogem Dale TOTAL: ISSUED BY: _�,_)
OFFICE