27931 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOmLB>'Nc-eLLUrR PERMITNO.
APPLICATION/PERMIT PLaMBIN'f;-MECHANICAL (] q
BUILDING DIVISION BUILDING PROIEC71ADENITFlCATTON J 1
BUIIG�L)Dlk(('lr(�� � D a SANITARY NO. APPLICATION SUBMITTAL GAT
1.0'1
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.RSN P' 07O P O CONTRA O '$IrI LIC NO:
J,,. lk
NC CONTROL
ARCHITHC'/ENGINEER: LIC NO: ADDRESS: /g �/y ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG F.LECf fli MECII
PERMIT ISSUANCE El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
QwZ Iherehy ar 1hw1amlicemodundcr ions ofCTepter9(commencingwith JOB DESCRIPTION
Poo[ ScOna9X111 1 eBusine )Professions CWa end myliceme is in PANELS
eeZU full force.
ef(et IV�Y"!`+I,fA`9N\�I►l 1/I Y„+LNL
Fyly license Clas Lic.p UP T0200 AMPS Y/ V
.�Q a• Dmc Convacmr 201 1000 AMPS
F"yuo ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.IT.
Z O'^` I ande...and n plans shall he used us puhlic records. OVER 1000 AMPS
OZ-0
PL SIGNS EL ICAL
Q`S,,j Licensed Pirmfowional
Y OWNER-BUILDER DECLARATION 'CIAL CIRCUIT/MISC.
C
XCe. I hereby anon Ihap I an exempt from the Contmnors Littrtu Law for t
W3a following reason.(Section 7031.5,Business and Professi ounty TEMP.METER OR POLE MST.
�u'�; which reyuiresepermit to conaWCL elpeq improve, mulish,or rcpvr any aWnure
f�YS prim to its issuance.also rcquircsthc applicant for su pemduo fileesignW stamtrtenI POWER DEVICES
y�jCOp Ihm he is licensed pursuennolhe provisions of the nmructor's License Lew(Chepmr SWIMMING LELECHtIC
dXe� 9(commeraing with Section 71100)of Division3oft<Businen and RofassionsCWe) VALUATION
l4_y or that he is exempt therefrom and the basis for thea aged exemption.Any violation of ETCHES-FlXTU 5
F Z Q Section]OILS by any applicant for a permit suhjec the epPlicunp m u civil pevlry of
t more than five hundred dollars W00). N FNTIAL EL .FT.
� � n❑ Lasownendthcpropeny,army employeeswirM1 agest i...lecompereation, STORIES TYPE CONSTRUCTION
a3— will Bothe work.and Nestmmumis not intended oroffe Jforsole(Scc.]0a4,B sinus
and Professions CWe:The Commerce.License Law s not apply to an o r of
propenywhobuildsorimporestimmon,andwhodcessa wnrkhlmselfunhro chi,
empleyees.providW that such improvemcros are not in nJW wo(fered Tor f OCC.CROUP RFS.UNI IS
however,the building orimgmvemem is Bold withaln one ye necrotic'an,the me TOTAL:
builder will have the burden of proving that he did not build r improve for puryose tf
rile.), p QTY. PLUMBIN ERMIT FEE
❑ I,as ownerat the progeny.nmeaclusively contracting wit licensedcallourterse FLOOD ZONE APN
construct the project(Sec.7144,Business and Professions C :)The Contractor's
License law docs not apply manownerofPropeny whobuildsor provesthearmand PERMIT ISSUAN
who contmeD for such projects with amnlracter(s)licensd pursu come Contractor's
License Law. ALTER-?KA at VEN'T'-WATER(EA) FEE SUMMARY
❑ I ant exempt under Sea ,B&P for this reawn BA • OW PROTECT'.DEVICE -FEE
SANITARY Y N
Owner DateDRAINS-FlAOR.ROOF,AREA,COND. RECEIPI'a
WORKMAN COMPENSATIONDECLARATRATION SCHOOLTAX Y N
❑ Ihercby affirm thou have acenificntepe of fwcomem to ulLinsum.ore ttnifi<am of FIXTURES-PER TRAP RECEIPI'a
Workers'Compcnsxnlerthisermit. ificJ copy thereoflSm.3800,Leb C.)wM1ich PARK FF:E Y—N
covers all cmploycc's under permit. GAS-EA.SYSTLM-I INC.a OUTLITS RECEIPTDIVISION
Policy N BUILDING DIVISION FEES
Company GAS-FA.SYSTEM OVER 4(IIA) PLANCHECK FEE
❑ CenifiWeopyisherebyfumished.
❑ CeniOed ropy is fled with the city inspection division. GREA$EBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE MAP SOILS FEF,
COMPENSATION INSURANCE
(Thissection need not b,completed Hall,permit is(crone hundred dollars 0100) :TL-DESANITARY-STORM EA.2(X1Fr. ENERGY FEE
or less.)
I ccnify phot in the perfornanceof the work for which this permit is issued,Ishall WATER HEATER WNENf/ELECTR
not employ any Person in any manner ser as to become subject to the Workers' PAID
Compcnsmionlawsof Culifnine Dole WATER SYSTF.MiTTEATING Dam RaceiptN
O z Applicant
0 NOTICE TO APPLICANT:If,after making this Cadificae of Exemption,you should NEW RESIDENTIAL PI-MB. SO,FT. TOTAL:
t-' become subject to the Workers Compensation provisions of the Labor Cradle,you must
FFFFC4----"'' > forthwim comply with such provisions or this permmed
it shall be deerevoked. BUILD]NO FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thatherc is a construction lending agency For the performance of
u O the work for which this permit is issued(Ser.3097,Civ.CJ TOT .: ,Nai ELECTRIC FEE
Iamder's Name
u"' F Leader's Address QTY. MECHANICAL.PERMIT FEE PLUMBING FEE
U 1 terrify that I have road if application and state that the above infmmalinn is MECHANICAL FEF.
correct.lagreemcmnplywi al cityatdcount mcbra casaMsamlaws rcl.firgin PERMIT ISSUANCE
building construction.and h by uthrcorizentetivesofthiscit toentarti nthe
V Z above-mentionedrony
ppeor icti
peunpurp, y ALTER OR ADO TO MEC]{_ CONSTRUCTION TAX
(Wc),smeni rude nifyand ft less th of CuPmanor against
liabilities,judgments, .cis expense yin an y accrue against said City AIR HANDLING UNIT(TO 10.0010 CFM)
it rnnsequ ago
is AIR HANDLING UNIT(OVER 10,000 CFM)
Sign re c,mBConmmt Date EXHAUST HOOD OODUCT]
PAID
IIALARDOU 'RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date RcceiptN
Will the 0m Criasiram Municipal
Code.
9.o,M1il the Health and Safely
HEATING UNIT(OVER I00,000 BTU) )T
as defined by Ibe Cupenino Municipal CW<,Chapter 9.12,and the Health and Safny
Code,Section 25532(a)? VENTILATION FAN(SINGLE RFSTD)
❑Yes ❑No
ISSUANCE DATE
I iHcappFicmmr future building occupant ussequ]pmenmrdeviceswldchemit BOILER-COMPf3HPOR IW,Uq BTU) q 1QQ
M1suNoux air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(X10 BTU) p�e M 0045
DistricR n n
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
I have read the harmadfe,,Code,mctionss rc05,25533 under Chapter emu of the
CITY Ur uurtKllNU
ifthe buil ingdo&SalcuretlySections 25505,25533 andsponsi (undersand that
overipailofthe have a must ar monis my responsibility Cesnmify the �/ L
swcupum of the requirements which nun be met prior to issuance of a Ccnificate of
Owner or aulM1oriuJ agent Date TOTAL: ISSUED BY:
OFFICE