27275APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO RHH.HA- hA.hUrRICAI
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUII,UING DIVISION BI1ILD NG PROJFCIIDENTIFICATION
PERMO'NO.
27275
Il -DING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE:
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NERS NAME: PHONE CONTRACI'OR'SNAME: LIC NO:
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1RCIH1 ECT/ENGINEER: LIC NO: DRESS:
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- BUILDING PBRLUM INFO
BLDG IiL- PLUMB MECH
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CONTRACFOR'S DECLARATION APPLIANCES -RESIDENTIAL
Ihereby affirm that l am licensed under provisionsofC'hapter9(commencing with
Seeion 7000)of Division 3mtlm Busincssand Prnfessionx Code, unit an, license is in PANELS
full forecind effect. UPT02m AMPS
LicenseClass Lic.p
Date Contractor 201-10(p AMPS
JOB DESCRIPTION
ARCHITECTS DECLARATION OVER 1000AMP5
I understand my plans shall he used as public records. C-�
SIGNS ELECTRICAL
SQ. PT. FLOOR AREA
f/SQ. ET.
licensed professional
y d'Q
3 Oa to
0. vFi
ES NO¢
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E:n O
W _rn
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OWNER -exempt from the ComTION SPECIAL CIRCUIT/MISC.
I hereby n.affirm(Se that 1 am exempt from Ne Commences Co License law for the
following reason (Section co3LR Business end Professions Code: Any city or county TEMP. METER OR POLE MST,
anpermit reconstrue,pplicimprove. h perraftt firepair nnystructure
priormits issoence, also requires Neeeelicent for such permino fileesigned statement POWER DEVICPS
prirM1 its
Nat he is licensed maximnn the provisions of the Contractors License nIoW (Chapter
9(commencing with Section 70001 of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
or that he is exempt herefrom and the basis for the alleged exemption. Any violmionnf
Section 70315 by any applicant for aTeeth subjects the septicemia n civil penalty of OUTLETS - SWITCHES - FIXTURES
VALUATION
^1 O
G
�
p2
nm more titan Eve hundred dollars (Sem).
P a Y• NEW RESNENTIAL PI.ECTR —SQ,PT.
❑ ons ownemfdt ro n ofm
miners
1
STORIES
TYPE CONSTRUCTION
y _
isms
Cureactot is orofwageaaslheirmlrsade .7044, Business
dothewons
.i
and Coale he
Cale: The Contractor's Liveese Law mam
ase Law Jas not apply res rd owner
out
primary, wh builds find himxelforthmugh his
is
ternerls
'
OCC GROUP
RES. UNITS
own cru .,es,orimpmcesthereon,
measuchwork
far sale.
employemildirtgn,
such npnwementanremtinneardsular.fti
imrvemereborn
me,
brier of,mem issoldhe di innneynr oimprovfor theowner- TO DIS
howeer will have
builder will have the burden of proving that he did not build or improve for pumas of
sale.).
❑ I, as ownerofthe property, am exclusively contracting with licensed contractors N QTY.' PLUMBINGPERMIT FEE
FLOOD ZONE
APN
construct the project (See. 70,14, Badness cad PlOtessinas GWe:)'The Contmnora
License Law doexam apply eanmenerofpsopery whomildsorimprovesthermn,and PERMIf ISSUANCE
who contracts fasuch projects with acontracmr(s) licensed puxuanno the Contractor's ALTER FA
License law. ( )
FEE SUMMARY
❑ 1 um exempt unJer Sec. , B & P C for Nis reason BACKFLOW PRO'TIiCT'. DEVICG
SID: 7r[
Owner Da¢
SAN 1'I'ARY YN
RECEIPT#
DRAINS-FLOORROO .A, COND.
WORKMAN COMPENSATION DECLARATION ,
❑ Ihcreby off thstlhuveaceni0cme ofconum to self-insure,oracenificmeofRECELPfp
f1X'NRES-PER P
Wakers'Compensation insurance ora certifietl copy thereof (Sec.3Bm. Lab CJ which
overs all employee's under this permit GAS - EA. 'E -I INC. OUTL TS
Policy#
SCHOOLTAX Y N
PARKFEE Y
RECEIPT#
RUJI.DINF, DIVISirA FEES
PL.ANCHECK ME
Company
SV VER4(R
❑ niOed copy is hereby furnished.
El le
❑ C<nified copy is filed wird Ne city inspection division. GiA5 TRI.)CEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G TRAP
COMPENSATION INSURANCE
SOILSPF.E r V1
(This section need oat be completed Hite permit is for one hmbed dollars (5100) SEW SANIT Y -STORM FA. 200Ff.
or less.)
F.N' E
I certify that in the performance of the work for which this permit is issued. )shall ATER HEATER WNENTIELEC1'R
Z
not employ any Person in my manner so as to become subject to the Workers'
Compensation Lawsof Califomia. DateWAIT NSYSTISM/BEATING
Applicant'
PAID
Date Receipt#
O
V]
NOTICE TO APPLICANT. If, after making this Cenificare of Exemption, you should NEWR IDENf1ALP SQ. PT.
become subjecto the Warker%Compensationprovisioruofthelabar Code. youmust
TOTAL:
foMwith comply with such provisions or this ismaitshell be deemedrevnked.
BUILDING FE,.ieLO
(�
2
0
CONSTRUCTION LENDING AGENCY
I hereby affmt that iso cov
nmction lending agemy for the perfcmme, of
the work for which this permit is issued (Sec. 3099, Civ. C.) TOTAL:
SEISMIC FEE `
EL17CMIC FEE �.
IU
0.
Cz)
7
Lender's Name
Lender. Address QTY. MF.CHANICALPERMIT FEE
PLUMBING FEE.
I certify that I have rand this application and state that the above inrormstion is
correct.lagreemcomplywithallcityandcounty ordinances and este laws relntingto PERMIT ISSUANCE
building construction, and hereby authorize representatives ofthiscity ecaterupon the
calve -mentioned properly for inspection mr,re,s. ALTER OR ADD TO MECH.
MECHANICAL FEL?
CONSTRUCTION TAX
.7
(We) agree to first, indemnify and kap harmless the City of Cupertino against
Imbilhlex,jadgmenta, coslsand expenses which may in any way aca-ma,drid said City AIR HANDLING UNIT (TO 10,NX) CFM)
in cnnseyuena oft aniy�g of Nis permit. If
'/�ffi atGy AIR HANDLING UNIT (OVER IRXQ CFM)
Signature of Appiicatn/Contractor ,�j• Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,00) I3TU)
Date Recc I#
Will the applicants or future building acumart store or handle hazardous material HEATING UNIT (OVER IM." BTU)
as defined by the Cupenimr Municipal Code, Chapter 9. t2, and the Ib balm and Safety
7 AL:
Code, Section 25532(u)P
11 Via El No VENTILATION PAN (SINGLE RHSID)
,gms�ss
g�
building BOILER- COMP(3HP OR 100,tgN1 BTU)
it
Will thI,
ISSUA ATE
NOV
contaminants
nts as by the Bay Areipmentmality Mw agerre
hazaict? air contaminants as defined by the Bay Area Air Quality Mmagement BOILER- COMP (OVER 100,000 BTU)
District?
O ,J(Iaa _
❑ Yes ❑ No NEW RESIDENTIAL. MECH. SQ. M.
/�%y/Y(
1 have read the hazardous materials requirements under Chapter 6.95 of the
Califar isHealth&Safety Coale, Sectio..25505,25533 and 25534. 1 understand that
N
if the building does not currently have a tenant. Out it is my responsibility to notify the
wurmf tf the oxim1tntents which mast he met prior to issuance of n Cenificate of
Occupancy.
J,_
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ISSUED HY: vv_ R' l
Owner or mahrized agent Date TOTAL:
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