27299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' - PERMUTING.
PLUMBING-MECHANICAL C
BUILDING DIVISION BUILDING PROJECT[DEN"TIFICATION S.
RUILDI NO ADDRESS: SANITARY NO. AP1PLICATIOaN�SUBMITTALDA'I'
UNIT# LOT#
OW' NAM I PHONE—
CTOR'S NAME LI NO N/C ` CONTROL#
R52-
•AR IIF. NGINE' : LICNO: ADDRESS: ❑
CON'T'ACT PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG E ECT PLUMB MECII
PERMIT ISSUANCE 11 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑yZ Ihereby affirm that l an licensed underpmvisionsofaapter9(commencingwiih JOB DESCRIPTION
WOOSection 7000)of Division 3 ofdhe Business and PmEssords Code, ndmen
ylicseisin PANELS
FaU6 1[[force and effedl / I
F Z W License Class C� Lic.a UP TO NO AMPS
Fjh Dare Contractor 201-1000AMPS
ZO,Z CHITECTS D' OVER IIXIO AMPS SQ.1-7.Il.O AREA $/SQ.FT.
O Z— I undecaanJ my plum shat l be used as public raorJs.
f t? SIGNS ELECTRICAL
E� Licensed Professional
z,zQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aXO ayV. I hereby affirm that 1 am exempt boon the Contractor's License Low for the
W 3 u-en following ruaon.(Section]031.5.Business and Professions Cade:Any cityor couny TEMP.METER OR POLE INST.
O which requires a permit to construct,alter,improve,demolish,or repair any somence
Prim do tr noses cc,Wsu requires the epplic tfmauchp miOo filtaoigoedstamment PoWER DEVICES
m
'<0 that he is licensed putsuanrao the provisions of1he Cenc s License Law(Chapter
a
Y pioLL 9(wnunencing with Section 9tg18)of Diviam.3ofthe Business and Pro[essions Comm SWIMMING POOLELECTRIC VALUATION
Xm_, or that he is exempt therefrom and the basis for the alleged exemption.Any violetionof OUTLETS
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pen -
penalty of SWITCHES-FIXTURES
not mart than five hundred dollars($500b,
wtm ❑ Lasowncrofthe n NEW RESIDENTIAL ELECIR —SQ.FT.
prnpe yne is ammployeeswlthwidfar atirsole 01,L Buadon, STORMS TYPF:CONSTRUCfIOt
L'S— will do the and the h.Cireisnm',
License Law does sale alyt044,Business
and Professions CrtJr:The Conrocmm.License Law does or apply if rt owner of
property who but ids or improves thereum and who am n such work N rower ed through his
employebuildi gorithatsuch improvementsamnot year
ofcoroffcred for oushef, OCC GROUP RBS.UNITS
howevew the avethe burden of emem issoldhe id oneyea ofcompheion,for drepropose of O' L:
builder will have the burden of proving that he did not build or improve for purpose of
aJeJ.
❑ I,ct owncrofc'(See ny,amcxclusively<onraauions Cllcensed wnracmrsm QTY. PLUMBING PERMIT FEE FLOODZONF, ppN
mine rhepes not(Sec. arra Businesssend Pwhobinm Cr inamse Contractors and
licewhocclswdcesnm applymanowncouraclloom wM1nsedpsmimprothe Corwn,and PERMIT ISSUANCE
whocnmmas for such projmtwith acommcmgs)licwscd pursuantm the Conrsaora ALTER-DRAIN&VF.NT-
Lieenu wan. w .R(EA) FEE SUMMARY
❑ 1 am exempt undo Sec. ,B&P C for this reason BACK ITOW FROM EV ICE OUTSIDE FEF'_S
SANITARY Y—N
—
WORKMAN
Dat° DRAINS-FLOG OOF,AREA,CO RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IhcConTemat thmlhrance unifiwtepf conscmmself-insnre,or acda C.)woof FIXTURES- TRAP RECEIPT'#
Workav'employee', Ins
ifieJ copy themof(See.38W,Isb C.)which PARK FEE Y—N—
Pat!,
rs all employee's under this .it. RECEIPT p
swim, GAS .SYSTEM-I I .4 OUTLETS
BUILDING DIVISION FEES
Company f
❑ Ccnified copy is hereby fum ,AS-EA.. STI- 4A
ished. (' ) PLANCHECK FEE
❑ Cmified copy is filed with theciy inspection division. GREASEpNDUT ASM I M R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SE SOILS PEE
COMPENSATION INSURANCE
(This section rainfall becompleted if Ne Permit is for one hundred do ars(SIOD NITAR - .2001". ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued, hall wA I ' TERW /ELEM
not employ any person in MY manner so as in become subject to the Wo h PAID
z Compensalol Utt000f California. Dam WATER TEM(GUEATING Dme Raeiptp
Applicant
0 NOTICE TO APPLICANT:TL after making this Cenificam of Exemption,youshould NEW RESIDENTIAL PLMJL S r. TOTAL:
f" lq become subject to the Workers Compensation provisions of the Lumr Code,you must
forthwith comply with such provisions or this permit shall be deemed revokd
e .
7 BUILDING FEE
LU
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm tha there is a conaruaion lending agency for the aft..of
C) O the week for which his permit is issued(See 3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
w0 U Lenders Address QTY. MECH ICAL PERMIT FEE PLUMBING FEE
P-1 I certify dant I have read thin application and state Nat the above information is
E•-' C. income I agree to comply with all city and county ordinances and slam laws minting to PERMIT IS CE MI'CHANICAI.FEF.
Ce) building construction,and hereby authorize representatives ofthis city[center upon the
f,) Z Mawc-memioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to trust,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgments,cost and expenses which may in my wayacerue against said City AIR HANDLING UNIT(TO[y0pu CEM)
a. Rhe ming of this permit.
� _1 '1 AIR HANDLING UNIT(OVER I0,000 CFM)
A—
Siyrmure of rt�,mraet 6 Date E%HAUST HOOD(W/DUCry
PAID
HAZARDOUS Mng occALS DISCLOSURE HEATING UNIT(TO 1W,000 B'fU) Dote RaeiptM
Will the applicant of furore building occupant sort or handle hazardous mmerial
as defined by the Cupertino Municipal Code.Chapter q.12,and the Health and Safety HEATING UNIT(OVER 100,000,oBTU) TOTAL:
COM,,Section 25532(x)?
0Yes 0N VENTILATION FAN(SINGLE kGSTD)
� Willthe applicant orfmure building Occupant use eyuipmemnrdevices which earn
BOILER-COMP(311P OR I W,WB BTU) ISSUANCE DATE
dazallous air condnminwits as defined by the Bay Area Air Quality Management BOILER I(p,010 BTU)
isrim?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. say ® p1
1 have mail the hazaJous matduls reyuiremems under Chapter 6.95 of the [I/o� ll//
California lfeahh&Safety Cade.Sections 25505,25533 and 25534.1 understand thinJI/ F
if the building does not currently have u must,that it is my msponsihility to notify the ad
oecupam of the"micmems which must be met prior ,m issmnee of a Cenificam o! Cq 7
panc
Occuy. I�
(honer or vmM1mmd agcmDara r
TOTAL: ISSUED R k�I
OFFICE