27982 APPLICANT TO FILL IN INFORMATION WITIJIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-hL=CI'RI AIPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27982_��O n
G
BUILDING PRO.IECT IDENG'TIL+ICATION o
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI?
�
LOT« q
OWN R PHONE CONTRA OR'S LICNO: N/C CONTBUT
ARCHI 1ECT GINT?LR: LIC NO: ADDRESS: El "`7`
CONTACT: - PHONE:
QTY. ELECTRIC PERMIT PF;B BUILDING PERMIT INFO
SLUG EI PLUMB MUCH
PERMIT ISSUANCE INRs ;KI—. UCH
LICENSED tIaml CONd ACT underOR'Sions of RATION AI'PLIANCI?S-RCSIULNTIAL JOB DESCRIPTION
pyZ Iherchy affirmNatl am licensed undcrprovisions ofCl w—�
�s100 Sectiorecand)efDivision Sof the Business end Professions Code,and my licenu is in
PANELS ,�`•;'•[✓�
y WWF full Losec lass effect.
FyW License ClassLic.p UPT02W AMPS
y6y Dale Contractor 201-1((10 AMPS
FO ARCHITECTS DECLARATION SQ.IT.F}.00N ANEq EISQ.hT.
ZO..ZJ OVER IOW AMPS ^(�` ,��{1..+a1 (/pvLIrM1I
OZ-'G lundentand my plans xCHT used ns public DECLARATION
F y ltW - SIGNS ELECTRICAL
gg Licensed Professional
OWNER-BUILDER exempt
To DECLARATION theCommune SPECIAL CIRCUIT/MISC. 2,0Z
`
iMqJS� c, 1 hereby affirm that 1 am exempt(font the GmionsCo License Law for the a✓1L Lir
RJ'3Wm¢ following reason(Section'l03 L5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�0.] which requires a permit to construct,alter,improve,demolish,or return any structure 1 O4 ��
pdr,l.0 ismmace,al-on,ire.thea,icunt forsuchpernho,HT...ignedxmrement POWER DEVICES `
DO that he is licensed pmsmnt to the pmvi,inas of the Contractor's License Low(Chapter
o.axo�' 9(commencing with Section]O(IMof Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ul_rn orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCI{pS-FIXTUNES ( �_
�4 Section 7031.5 by any applicant for apermit subjects the applicant to a civil Penalty of v!'
not more than five hundred do]].($500). NEW RESIDEN
ec m EI1,mownerofNel Waymrmyemployeeswitbwagesastheirsolecompensafair TIALELECTR _SQ.FT.
STORIIIS TYPE CONSTRUCTION
ywill doth.work,and the structure factor imm�dese La does
apply
70a4,Business 11 may.
and Professions Code:The Contractor's License Law Joos not apply to an owner of
propertywhobuildsmimmosex Thomson,and whodocs such work himselforthrough his
I ees,provided thatsuchim OCC.GROUP RI?S.UNITS
stop oy prosoldwi ntime iearrofdopletiod formic.he
however,thc hue the burden
ov vinentg that he did not buildofaprobseion,turposer-
builder will have the burden of proving that he did not build or improve for purpose of
ownerof the pmpenY,emexduaivdyconvacting with licenudcammemrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
instruct the project(Sec.7044,Business and professions CNet,The Contractor's
Icemelaw doesnnt applyro an ownerofproperry who builds or improves thereon,and PERMITISSUANCE
whocommenforsuch projects with a contractogs)licensed purauanuothe Contreame. ALTER (FA)
\ [.lot.Law. FEE SOMMARY
[II am c rapt order Sea •B NI'�C Rn BACK p1.OW PROTI?CT.DF.V IC OUTSIDE :P.S
SANITARY YN
e me RECr:119'p
DRAINS-ItOOR,ROOF,ABPA,C
WORKMA COMPENSATION DECLARATIONSCHOOL TAX Y N
1 herehy affrm that 1 have u eenificnre of consem to self-insure,or a cenilimw of ?L
FIXTURES-PER TRAPWorkers Compcnamion latmon,ora ccnified copy theend(See.3800.lab C.)which PARK FEE Y N
Poen all employee's under This Permit. GAS-EA.SYSTEM-IINCAOUTLETS «
licyp B IS ION PCE$
Company GAS-EA.SYSTEM-OVER 4 THAT PIA li( E
❑ Cenifiedeopyisherebyfurniahed.
Cl Cerifiedcopy is riled with the city inspection division. GREASFANDUStRL WASTE INTERCEPTOR ORIGIN
C'ERI IFICATE OF EXEMPTION PROM WORKERS' GREASE'TRAP
COMPENSATION INSURANCE
(This section ouJnot be completed ifthe permit is(arose hundreddollara(S100) SEWER-SANITARY-STORM EA.200FT. bu
`
.r less.)
I certify that in the performance of the work for which This Permit is issued,I shall WATER BEATER W/VENT/BLECTR
not employ any person in arty marmer so in to become subject to the Workers' PAID
Compensation Lawsof C.IOmmia. Date WATERSYSTEW REATING Date RccciptY
O Z Applicant
Z NO HCE TO APPLICANT:IL after making this Cenifieme of Exemption.you should NEW REST DENTIAI.FLM& SQ.FT. TOTAL:
hecome subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions arms pmich.Aull be deemed revoked. BUILDING FEE aaa«
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEL'
V z I hereby affirm that then is a construction Tending agency for the performance of
the work ELECTRIC ItiC
O for which this permit is issued(Sc 3097,Civ.C.)
Lenders Name
O F IxnderPLUMBING FEE
s Address QTY. `MECHANICAL PERMIT FEE
U 1 ccnify that 1 have read this application and state that the above information is
>" a erect. l agree to comply with all city and county ordinances rand state laws relating to PERMIT ISSUANCEMECHANICAL FEF.
F' rA building canstructlon,and hereby acthonee mpmseniati,snofthiscity an enter upon the CONSTRUCTION TAX
L) Z above-mentioned Properly for inspection purposes. ALTER OR ADD TO MECIL
^•' (We)agree to save,indemnify and keep mardes.the City of Cupertino agairat
ludilities,judgments,cnstaand expenses which may in my way acerueagainst said City AIR HANDLING UNIT(TO 10,000 CPM)
in consequence of the granting of This permit.
AIR HANDLING UNIT(OVER 10,000 CIM)
Signature of ApplicanUContractor Date EXI IAUST 11001) W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOL000 BTU) Dam Receipt«
Will the applicant or future building occupant store or handle hazardous material IILATING UNIT(OVEN 1 W,IIf(1 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Saurian 25532(a)7 VENTILATION FAN(SINGLE RESID)
11 Yes ❑No
BOILER-COMP UHP OR 1(81,0(X1 BTU) ISSUANCE DATE
Will air
co arromantsa s building by the
nBay A Air Quality Management 0 ['s 8 �J
dam air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r G�
ict4
❑Yes C3 No NEW RESIDENTIAL MECH.—SQ.Ff. 'I �(](3C
I have stud the harardous marerials requirements under Chapter 1Ialfl
.95 of the K 1 JJU
California I leahh&Safety Code,Sections 25505,25533 and 25534. 1 unde"Ord that
if the building does or currently have.anaalthar it is my responsibility to notify the -Hills)
cupmi of the requirements which must he met prior to issuance of a Certificate of `vl I Y U
Occupancy.
Ali
Owner or authorized agent Date TA ISSUED BY: _
OFFICE