27722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B 1 LDING-ELF, TRI AL PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n
BUILDING DIVISION BUILDING PROJECT IDEN'T'IFICATION G
7722
BUILDINGADDRCSS: SANITARY NO. APPLICATIION SUBMITTAL DATE
UNIT# LOTH 3-,? - (�
WN: A E' 1'H E: CONTRACT'OR'S NAME: LIC NO:
A 43 r, AMAr NIC CONTROL#
RCIII'1'1!CT/E GINE. LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECFRIC PERMIT FEE BUILDING PERMIT INFO
BLDG [LO PLUMB / MO I
PERMIT'ISSUANCE
LICFNSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ozz I hereby affirm that l am licensed underprovisians of Chapmr9(commencing with TOB DESCRIPTION
lg00 Semian RNNry of Division3nf the Buxinesa and Professinnx Codd,anemylicameisin PANELS
y�+�IC full force and effect's Lm#� UPT0200AMn
66NyU Liana U �wI
6t' Date Contraclar err 201-Iqp AMPS
ZOhZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Ff.FLOOR AREA S/SQ.NT.
O Z—O I understand my plans shall fenced.,public records.
(=m5; SIGNS ELECTRICAL
Licensed Professional
�Kd'¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
S�'OaF I hereby affirm that 1 am exempt tram the Contractors License Lew for the
Iz13�H followir,maxon(Section 0031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Sees which requires a permit to construct,alter,improve,demolish,or repair any sracture
a �.A prior to its iasuwsce.alsorequims fleappreant for such permiuo fileasignedswmment POWER DEVICES
pt'
E<0 that Ito is licensed pursuant o the Provisions of the Contractor's License Law(Chapter
d o 9(commencing with Section7"Blif Division Jofthe Business sand Professions Code) SWIMMING POOL ELECTRIC VALUATION
I '^y or that he in exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCIII!S-Fl%TURES
F. a
Section 7031.5 by any applicant fora permit suhj«tsthe application civil Penalty of
t�liSp ❑ [more than five ordred do][.($500). NEW RESIDf?NTIALELLCTR _SQFT
❑ IyaowneroflheproPrty.ormyemployeeswithwagesasmpc
eirsolecomnsation, . . STORIES Will:CONSTRUCTION
a3— will do he work,and the swcture is not intended or offered for sale(See.7014,Business
and Professions Cole:The Contractors License law dao not apply to an owner of
property who builds or improves thereon,and who das such work himself or through his
own enq]oyees,provided that suchimpmvcmulaarenot intendedoroffered formic.If, OCC.CROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner.
buihor will have the burden of that he did not build a int rove for u f TOTAL:
proving P purpose
®IeJ.
[II,asownerorthepmpay.amexelusivelycantractingwithlicemedcontracmrsto QTY. PLUMBING PERMITFEE FLOOD ZONE "N
construct the project Ser.7014.Business and Professions Code:)The Contractors p1�
License Lowdoes not apply to an ownerofpropeny whobuilds orimprovee tM1ereon,un0 PER 1'1.5 C J �-+
whocon0aas for such projects with acommmar(s)licensed pursuant to the Contractors AL IN -WA'fPJt EA)
License Law. ( FEE SUMMARY
❑ 1 am exempt under&c, ,B&P.C for Nis reason BACK 11.6110 UDS I DE FEES
,�fT.DEVICE SANITARY Y N
owner Date RECEIPT#
O
WORKMAN COMPENSATION DI?CLADRAINS-FLOOR. REA,COND.
RATION SCHOOLTAX Y N
$ ers'Co affumthat lheveacenificamof consenuo.f(Seeure,Or Lub C.)which
RECEIPT#
keri Compensationlnsuranaornttnifiedcopy thereof(Sec.JgOp,Lab C.)which Fl%TURCS-PER TRAP PARK FEE YN
covenallemployee'sunderthisperrgjs,�_U eZ as OAS-BA.SYSTEM-]INC.4 OUTLETS RECEIPT is
Policy#�¢�]���LL—OO R BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PfANCHFCK FEE
CeniRed copy is hereby famished.
Certified copy is filed with the city inspection division. GRPASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thiasection neN not he complctedifthe permitis formehundreddollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or leas.)
I certify that in the performance of the work for which this Permit is issued.I shall WATER HEATER W/VENT/ELECIR or 19
0�
not employ any Person in any manner so as to become subject to the Workers' PAID
Compenxtnlan Laws of Calif..!.. Data WATER SYSTEMIDIBATING Data ec ip
O Z. Applicant
Z 0 NOTICE 1'0 APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ,FT. li TOTAL:
F' V) bmannumbiectra the Workers Occupation..Provisions afdod Labor Cale,you must
a � forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FRE
Z CONSTRUCTION LENDING AGENCY SEISMIC PER
1 hereby affirm that there is a construction lending agency for the perfmmatim of
U Othe work for which this Permit is issue �ks ELEC
d(Sm.309),Civ.C.) TOTAL: TRIC IEE
LL E Lenders Nnt
ae PLUMBING PE
C) Lenders Address QTY. MECHANICAL PERMIT FEE
1 certify that I have toad]tis application and into that the above information is
w correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICALFE
building construction.end hereby authorize representatives of this city to enter upomhe CONSTRUCTION AX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR I IANDLINU ON I'I'(TO 10,800 CPM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Conwcmr Data EXHAUST HOOD(W/DUCT) PAID z
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(To 100,003 BTU) Dam Receiptp
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 B HD TOTALYJ:
El No Craft,Section 25532b)'! VENTILATION PAN(SINGLE RESID)
❑Yes
BOILER-COMP(311P OR 100000 BI U) ISSUANCE DATE.
Will the uppliwmw
orfnre building«cupantuseequiprr¢ntnrdevices whichem ,
it
hazardous ab contaminants m defined by the Bay Arca Air Quality Management 2 25�
oistr;cta BOILf:R-cGMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
I have read the hazanlous materials requirements under Chapter 6.95 of the
California health&SaliN Code,Sections 25505.25533 and 25534. 1 understand that
Wife building d v haveemne thmit is my responsibilI.ity the
occupant of Ns r n or m issuance of o Certificate of
O cup da
Owner raw oozed agent Date TOTAL: ISSUED BY:
OFFICE