25907APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO-
BUILDING DIVISION APPLICATION/PERMIT
,.. 'CTRICA
PLUMBING -MECHANICAL
:IIUII.DING PROJECT IDENTIFICATION
PERMITNO.
C A 0
J J
BUILDING ADDRESS:11 ` /�,
20 (� (y� S7- N `
\ I�
UNIT# LOT#
SANITARY NO.
APPLICATION SUBMITTAL DATE.
/'L e�
O NEItS NAME: 'HONN
CONTRACTOR'S NAME: LIC NO:
N/C
❑
CONTROLtl
_
IARC I ECT I FJ3: LIC
ADDRESS: -
CONTACT: PHONE: ��
�'` 1
'eA11'VL/'�(jLl�i, �M1����
xa 0. ` 15 4 "' kA . I:'te %'t h w, h. # f s r
Q ELFF TRIC PERMIxTeI t x ., , •FEE x
M n '�' y "x
4 4 .x : n .. -
` `r BUILDING PERMIT YNFO -
BLDG ELECT PLUMB MGCH
ekC
']J''�� lN� �C,,�.,I`L �'LCL,1 � 1
ER
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION
I herebyaffirm that l amlmonsed underprovisions of Chapw9(commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPI➢ON
Section ]00()of Division 3 of the Business and Professions Code, and my license is in
PoII f evididefl
PANELS
w
License Class Lia#
UP T0200 AMPS
Data Convector
201 -1000 AMPS
IV G Q.F OBR R $/SQ. FT.
ARCHITECTS DECLARATION OVER 1000 AMPS r P
I understand my plans shall be, used as public records.
SIGNS
I� �j F 0 O T
��fu I�
Liwnsul Rnfessionnl
OWNER-BUILDERDECLARATIONthe
PECIAELECTRICAL
SPECIAL CIRCUIT/MI$C.
1 hereby n. Se that 1 am exempt from the Cnmons Co License Law for the
Contractors
following reason. Section 7031.5, Business and Professions Code: Any city or county
nn
TEMP. METER OR POLE INST.
wthen requires a permit to construct, al ler, improve, demolish, or repair any structure
-
pricrtoitsissuance,alsom ires the applicant[orsuch permit to file a signed statement
POWER DEVICES
that he is licensed pursuant m the provisions of the Contractor's License Law (Chapter
9(wmmencing with Section 7") of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OUTLETS-SWITCHES-FIXTGR85
not more than five hundred dollars ($500).
ElI,asowneroftheproperty,ormyemployeeswithwagesastheirsolecompensadon,
NEW RESIDENTIAL ELECTR SQ. Ff .
STORIES
9YPECONSTRUCTION
will dothe work,and thealruclum isnot lntendedoroffinad forsom(Sec.]044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
14J" Pkv�
property who builds mimpoems thereon, andwhodossuchwork himselfmthrnughhis
ownemployees,provided provehlmprovementhin ne
OCC. GROUP
RES. UNITS
yearo complfered theo..If,
however, the building or improvement is sold within one year oPcampletlon, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sole)'TUU
❑ I, us awnerof the propery,emaxclusrvely conlmnmgwrthlicensed contrectoreto
construct rho prefect (Sec. 70.4,l, Business and Professions Coda) The Gun...... e
License Lawdoes not apply to an ownerofproperty whobuilds or improves thereon, add
.. , , ...
QTY'?-x+sox PLUMBING PE,RMITa` �FLBe`'?
PERMIT ISSUANCE
FLOOD ZONE
APN
who amtracts fin such projects with a eonvaotor(s) licensed pursuant to the Convenor's
License Law. -
ALTER -DRAIN&VENT - WATER HIA)
"" FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT'#
Owner Dam
WORKMAN COMPENSATION DECLARATION
DRAINS- MOOR. ROOF, AREA, COND.
SCHOOLTAX YN
❑ I hereby affirm that l have a ounificam ofcoosentto selFlnsure,oraoernficate of
Workers'Compensadon Insurance or acertifiedwpy thereof(Sec. 3800, Lab CJ which
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
covers all employee's under this permit.
Policy #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Company ertified copy is hereby famished.
GAS - F.A. SVS'fHM-0VER 4 (EA)
PLANCHF:CK PEE
either' copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
ENERGY FEE
("Un.anionn.ed nolbe completed ifthe Ismailia for one hundred dollars ($100) SEWER - SANITARY - STORM EA, 2001T.
or less.)
I certify that in Ne performenc.ofthe kfor which this permit is issued, l shall WATER HEATER W/VENT/ELECTR
not employ any person in coy marmer n to become subject to the Workers
PAID
Compensation Lawsof Califomia. Date
Applicant
WATER SYSTEbkrREATING
Data Receipt If
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, youshould
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensmion provisions ofthe Labor Code, you most
mt
forthwith comply with such provisions or this peushall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
-
SEISMIC PER
I hereby affirm that there is a construction lending agency for the performance of
work for which this permit is issued (Sec. 3[197, Civ. CJ
Lenders Name
TOTAL:
11 -
ELECTRIC HE
Lender s Address
' . r
QTY? �` . r - ,MECIIANiCAL PBRMTT: c # s { { -FSB
PLUMBING FEE
I certify that 1 have read this application and sam that the above information is
orten. l agree to comply with all city and county ordinances and stem laws latinglo
t
PERMIT ISSUANCE
MECHANICAL FEE
building construction,andhereby nwhorisompresenati ofthisrayme a upon the
above -mention. ..perry for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(Wo) egr ve, indemnify and keep hadde a City of Cu rtin against
_
liabilities,jud ns, costs code pen which in nyw aecmea Inst aid 'it
w
AIR HANDLING UNIT (TO IO,000 CFM)
unscyu n ft egrw[ingo Thi ammh.
IIW`\
-
L
AIR HANDLING UNIT (OVER 10,000 CPM)
Sig .,are. fA p ant/ omm,anr - Dam
EXHAUST HOOD (WNUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE
ABATING UNIT (TO 100,000 BTU)
Date Receipt#
Will the applicant or [alum building occupant store or handl. hamrdous material
Defined by the Capetian Municipal Code, CM1apmr 9.12, and he Health sad Snfny
BEATING UNIT (OVER IOo,000 BTU)
Code, Section 25532(x)'!
❑Yes El No
VENTILATION FAN (SING LE RPSID)
ISSUANCE DATE
� p
A D
rfubuildingoccupant mBOILER - COMP CHP OR 100,000 BTU)
Will the applicanmwre useequipme or which emit
hazardous air contaminants as defined by the Bay Ares Air Quality Management BOILER - COMP(OVER 100,000 BTU)
District]
❑ Yes ❑ No
NEW RESIDENTIAL. MECH.-SQ. FT.
California Health & Safety Code, Sections 25505, requirements
I have read the hazardous materiels requirements order Chapin understand
of thethat
and m, Ch l undersand that
hQf '%il
O
1J
if the building does not currently have a tenant, that it is my responsibility to notify the
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�
.cupant of the cNiu mannas which must he met pmm m lesuanee of a Certificate of
" Uf" V (J p.kl
Occupancy.
1
ISSUED BY' v
Owner or authorized ager Date TOTAL:
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