27708a.
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ..F. N AL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
PF.RMIT'NO.
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27708 7 7 OO O
BUILITNOpypR�$g:
SANITARY NO.
APPLICATION SUBMITTAL DATE.
6 !J( r/1/V// UNIT# LOT
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O R. N F.:
C O 'S NA 1
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❑
CONTROL#
F446 -
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ACI It'Owc 1717N INEBR: LIC NO:
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CONTACT: PHONE: /
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMITPLUMB FO
BLDG ELECT PLUMB MECH
PERMITISSUANCE
✓ ((�
IGCle-�I/ W'
❑ ❑
LICENSED CONTRACFOR'S DECLARATION
I hereby uffem Nat lam licemedanderprov m of Chapmr9(commencing with
rainV"�TINC
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Sechon700 ofD n the Business and ylicenseisin
full forte off t.
PANELS
I
License 1 a hie.#
UP TO 2W AMPS
w 1p'�Ta
Ue[e Contractor
ARCIU 1TCPg Df:
1 undent nd my plana shall M1e used m publi
201 - north AMPS
OVER IOW AMPS
SQ. FR FLOOR AREA
S/SQ. ITL'.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby from that I um exempt from the Contractor's License Law for the
EMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions CNB: Any city or county
which requires a pemdt to construct, alcor. improve, demolish, or repair any structure
psforto its issuance, alsorsquires the applicant fmsuch permit to file a signed statement
WER DEVICES
that he is licensed punoam ro the provisions of the Contractors License Law (Chapter
9 (commencing exem with Section ]fNm)the Division 3 Mahe Business and Professions Code)
S MMI G PO
VALUATION
that of
Sermon ]03 t,5 by any tsdiedesemant to civiny l
Section 7031.5 by tyapplic nt o the basPermit subjects
do[[ for a petmiuubjecn the applicant s civil penalty of
OU .FT 115-FIXT Wq
not momown ofihe roe rtyllarmSSW).
dyed
❑ Lmowok,andepmpeny,ormotinumyees compcmmion,
NEW I AL _SQ.FT
STORIES
TYPE CONSTRUCTION
will do the work, ofifengesaathelSee.
set far Business
Core- a Cuumcmeintendode Law do of apply to an
and Professions CNe: The Contnctar's License Law does not apply to an owner of
property whoes, proodmpnaamth Improved who does such work moffi fanhrough his
employees, provided thotauch Improvements ore no[imm�oeJ oroffered fonale. If.
OCC GROUP
RES. UNITS
however, the bulldingor improvement isanld withinons yearo!completion, the owner.TOTAL:
builder will have the burden of proving that be did not build or improve for purpose of
QTY. PLUMBINGPERMIT FEE
sine.).
❑ I. as owner Mthoproperty, am esetusively contracting with licensed commcmre In
FLOOD ZONE
APN
construct the project (Sec. 7044, Business and Professions CMIc:) The Contractor's
License Law does not apply m on owner ofpropeny who builds or improves thereon,and
PERMIT ISSUANCE
who contract; for such projeen with a contracmr(a) licensed punumto the Conerectoes
License Law.
ALTER (FA)
FEE SUMMARY
❑ 1 em exempt under Sa. B @ P C for this rtmon
BACK FLOWO
PROTECT. DEVICE
. IW
SANITARY Y
RCCIiIPTp
Owner DateOf
DRAINS- FLOOR, ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX ,YN
l I hereby affirm that l have a certificate increment to self-insum.or a cenificmeof
1 rs'Cnmpensar/jon sur c o it iedcnpythercof USec.380Q1ab C.)which
pIXTURFS-PBR TRAP
RECEIPT#
PARK FEE Y N
GAS - EA. SYSTEM -I INC. 4 OUTLETS
mvenall employal,t i e [
Policy# l O
RECEIPT#
BUILDING DIVISION FEES
Company40 1 P 141
Coni co r r utnish
GAS - EA. SYSTEM -OVER 4 (PA)
PLANCHECK FEE
GREASE(INDUSTRL WASTE INTERCEPTOR
GRADING FEB
ruffed copy is filed wilt city impen..division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS EEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA, 2001T.
ENERGY FEE
(This yvcllou Hood not be completed ifthe permit is for one hundred dollars ($100)
or less.)
WATER HEATER W/VENT/ELECTR
I sanity that in the performance of the work for which this permit is issued, l shall
so
not employ any pc. any m as to become subject to the Workers
PAID
Compensation Laws of C#lifomie. Dau
WATER SYSTF.MfTREATING
Data Receipt 11
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, ym.,hnutd
NEW RESIDENTIAL PLM. SQ, FT.
TOTAL:
beoame,mbject to the Workers Cma,mamim provisions of the L.No CNe, you most
forthwith comply with such provisions or this #count shall be deemed revoked.
BUILDING ME
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I heathy uffmt that the. is o consuunion lending agency for the performance of
the work lin which this permit is issued(Sec. 3097, Civ. CJ
I
ELECTRIC FEE
Lenders Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE --f
I certify that I have tend this application and state that the above information is
contest. I agree to comply with all city and county ordinances and state laws relining to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives of this city to enter upon the
ahuve-mentioned property for inspection purposes.
AIA HR OR ADD TO MECI I.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
may is any way accmeagiumt said City
liabilitsi�es,juidI�g.ments, casteandmpen8upse
AIR HANDLING UNIT (TO 10,OW CFM)
pw�h�ich
t.
locant}--Jf of [hehihl tpfiaeea//
AIR HANDLING UNIT (OVER HL" CFM)
EXHAUST HOOD(W/DUCO
PAID
Signature of Applis m for T Pare
HEATING UNIT (TO IW,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building mcupant store or handle hazardous material
as defined bytheCupcnino Municipal CNe, Chapter 9.12, and the Health end Safety
HEATING UNII'(OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE ESSIG)
CNe, Section 25532(a)?
1:1 Yes El No
Will the applicant or future M1vildingoccupontuu<quipmemordeviceswhichemit
BOILER - COMP OHP OR 100,000 BTU)
/0E
ISSjJpYW)P
C
BOILER - COMP(OVER 100,000 BTU)
hazardous air contaminants m defined by the Bay Arca Air Quality Management
District? ❑ Yes ❑ No7
1995
FEB
NEW RESIDENTIAL MECH. SQ. FT.
I have read the himrdaus materials requirements under Chapter 6.95 of the
Califomie [ImIth @ Safety Code, Sections 25505, 25533 and 25534. 1 understand that
����uT1N0
OF fl
if the building does not currently have a tenant, that it is my responsibility to notify the
C1lY
V 1 V
occupant of the requirements which must be met prior to issuance of a Crnifcate of
Occupancy.
ISSUED BY: 11
Owner or umhoriml agent Date
TOTAL:
OFFICE