27501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION PLUMBING-MECHANICAL BUILDING-ELECT RICAL PERMIT NO. O
BGlcumc mvlsloN APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: Vt - SANITARY NO. APPLICATION SUBMITTAL DATE
2 UNIT# LOT# ' �2�,��
OWNS NAM PHO# ACTO aAk1E: — — LCNO:� �+
l\�},e'�f ��•Q N/C CONTROLM
ILIC NO:4CRCHITECT/LN
ONTACT: PHONE: BUILDING PERMIT INFO
QTY. ,ELECTRIC PERMIT FEE
UMB MOH
❑ E]BLDG ELECT PI}Lar{IQ_
LICENSED CONTRACTOR'SDECLARATION PERMIT ISSUANCE APPLIANCES-RESIDENTIAL JOB DESCRIPTION
P tOC Thereby affitmthatlion 3 Offcensedunss it Pononsomb otic.and
my lemgwith
�i100 Section a and of Division 3 of the Business end Professions Cade,end my license is in PANELS
yW full force and effort. t
FyLicenxe Class LIC.# UP T0200 AMPS
W
mDz Uam - CaOtlmm 201-Iqp AMPS
z FO."— ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall be used as public records.
P4 -Wj LSIGNS ELECTRICAL
Licensed Profesvonel
�CWa OWNER-BUILDER DECLARATION SPECIAL CBICUE/MISC. -
00 F I hereby affirm that I sum exempt from the Ccomom r'a License Law for the
'3 tL m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,aper,improve,demolish,or repair any structure
'z g pmals
roo its issuance, urene
que thespplicam forsuch permit to file a signedsratemem POWER DEVICES
tiqO 4 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
Xa, 9(commencing with Section 70IXp of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W-,m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-
r Section 7031.5 by any applicant for a permit subjects the applicant to a civil FIXTURES
< 1Penalty of
� G not more than five hundred dollars($500).
C o ❑ I,the wrk,anhepropralumimyemployeeswithwed finsthe(Sm.wm,Busiest NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will Ir the end the he Contractor s License
a se La does not apply t oan Business
end PnNessions Cade:The Convector's License Law does not apply to an owner of
property w ho bu i Ids or i mproves thereon,and who does such work himsel f or through his
own employees,provided thermal,improvemmtsamm(intendedorofferedforssle.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within oneyearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,exownerofthepmWay,amexclusivelyemuntingwifilicensedcontracmrsw QTY. PLUMBING PERMIT FEE FLOODZONE AIN
antrum the project(Sec.7644,Business and Professions Code:)The Comrador's
License Lawdoesnotepply wan ownerofpnomy whobuilds orimproves thereon,and L PERMIT ISSUANCE
whoconnats forsuch projeaM with a cora statuds)licensed porsuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSID• EES
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF,AREA,CONE. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsent to selPinsure,ora certificate of FIXTURES-PER TRAP RECEIPT#
Workers'Campensation insurance or a certified copy thereof(Sec.380),Lab C.)which PARK FEE - Y N
covers all employee's under this permit. GAS-EA.SYSTERECEIPT#
Policy# M-I INC.4 OUTLETS BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
[I Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP -,r^s"Rmu SOILS FEE
COMPENSATION INSURANCE _
(This sectionneal n[be completed ifthe permit is foronehundred dollars($100) �SBWER,,S'AIy1TARY-STORM EA.200FT. �� ENERGY FEE
lea ifythetinlhersrfonnsnceofthe work for which this permklgfeea,; shell WATER DEALER W ENT L
Id
not employ any person in any manner so as In become sabjat to the Workers' PAID
Compensation Lawsof Califomia. Date T SY TINAData Receipt#
Q z O Applicant :,I
NOTICE TO APPLICANT:If,afterforthwithmpartialshking this Certificate of Ex¢mption,you Itlb NE RE9�lIj�J'f L LM SQ.FT.' TOTAL:
become subject to the Worker's Compensation provision de
of the Labor Ca ,youpRt
forthwith comply with such provisions or this partial ell he deemed revoked, l e `% $ BUILDING FEE
0CONSTRUCTION LENDING AGENCY Q:d' � �•I SEISMIC FEE
1 hereby affirm that them is a construction lending agency for the perfommance o
J O the work for which this Permit is issued(Sec.3097,Civ,C.) ELECTRIC FEE
:y,L;,
w ,.r Lender's Name •s, Sw?- ,,,,:
t-' Lender's Address ° QTY.e_,• ',,::.•MACflAfJICAL PERMIT FEE PLUMBING FEE \ /�
WI certify that I have read this application and state that the above infgnpmldnie- -'r"'
tract.Iagree to comply with all city and county ordinances and stum laws relating to PERMIT ISSUANCE MECHANICAL FEE
tibuildingsonstruction,andherehyauthonze preseamrivesofthiscitywenteruponthe CONSTRUCTION TAX
C) 7 above-mentioned properly f ecrfo uses. ALTER OR ADD TO MECH.
•7 (We)agree m save de srfy sn a the City of Cupertino against
liabili[ies,judgments,c rte en afar ormyi y way acerae against said Ci AIR HANDLING UNIT(TO 10,000 CFM)
in conte of the RhiI mist.
AIR HANDLING UNIT(OVER 10,000 CFM)
ran sof Applic Comrac[o Dem EXHAUST HOOD(W/DUCT)
PAID
ZARDOUSM ERIAIS DISCLOSURE HEATING UNIT(M 100,000 BTU) Data Receipt#
Will applicant future buil goccapentswre or handle hazardous mammal HEATING UNIT(OVER IW,OpO BTU) TOTAL:
m defin by the Cupertino al Code,Chapter 9.12,and the Health and Safety
ode.Section ❑es
No VENTILATION PAN(SING LE RESID) L
. IS ACT!
Will hee lioanmrf mrobulldin R-COMPHP OR 100,0
( 44 THE ^ A
PP goccopam useequipmemordevicee whichemit BOILE
hazardous air conmminunts ae darned by the Bay Ara Air Quality Management BOILER-COMP(OVER 100,000 BTU)
istnctP IDgn A� aye 1 '
Yea ❑No NEW RESIDENTIAL'MECIL SQ.FT. JA 81 19 5
I have read the hazardous materials requirements under Chapter 6.95 of the CRY Up Gj)� TINO
California Healfu&Safety Cade,Sections 25505,25533 and 25534. I understand that VI- L C7Y''A'
if the building does not currently have o tenant,that it is my responsibility to notify the
LIl 1.U/O
occupant of the requirements which must be met poor to issuance of a Certificate of
Occupancy.
Owner or cmmand agent Date 'TOTAL: ISSUED BY:
OFFICE—