27630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 27630 7 6 3 O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT EDENTIF'ICATION
BUILDING ADDRESS: �s /� mss ) SANITARYNO. APPLICAM)ISSUBMMIITTALDATE
DMFeO / ci/'I ��C/ UNIT# LOT#. y�— / S—
OWNS NAME: a PHONE: CONTRACfOR'SN E: LIC NO:
� `yn'T" �� Q N/C CONTROL#
MW CHITECT/ENGINEER: AD ESS: F-1s L�iai�1 d!
11
'aNTACf: PHONE: QTy, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
//JAI
/•�/+ �'�-G 7 7.0— PERMIT ISSUANCE BLDG ELPLUMB MCH
2-, OU
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyz Iherebyaffimvhat l am licensed underprovisions of CTeprer9JOB DESCRIPTION
with #
1400 SectionT000)of Division 3 of1he Business and Professions Cade,and my license is in PANELS yyJJ yy
F,y, Lilanse�C}�nsee�•�� Lia# UPTO2MAMPS
w=y � — a� y 201-I"AMPS
2O,6ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ,Un
understand my plans anal[be used as public records.
r"i Lmensetl Professronul SIGNS ELECTRICAL
0. «<<66 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x O y U 1 hereby affirm that I am exempt from the Contractors License Law for the
W 3 R.m following reason(Section 1031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�'ON; which requires a permit to construct,alter,improve,demolish,or repair any structure
Y� prim to its issuance,also requires the applicant tinsmith pernit1.fileasiloudstatement POWER DEVICES
ly q O that he is licensed pursuant to the provisions of the Comraetin,License Law(Chapter
oF,4 9(commencing with Section 7003)M Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,that he is exempt lherefmmanJ the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES- �/
P Section 7031.5 by any applicant for a permit subjects the applicant to a civil FIXTURES
�Q m
j pp Penalty f
W q not more than five hundred dollars(SSW).
W m ❑ Lus owner ofdeesonalmovi,net
imendedearafcom fiuethei(sole compensation, NEW RESIDENTIAL ELECTR -SQ.Fp. STORIES TYPE CONSTRUCDON
p, will domework,and the he Comisnot ern License
Law
dos not apply t 044,Business
and Professions Code:The vesthe tors License Law does not apply to an owner of
propertywyees.prolds admpmvesthereon,anmentsa m ti mendrkhimfferedhroughhis
can employees.provided i pr vemenprocementsareneyear dedo(offered thea e. r- OCC.GROUP RES,UNITS
however,the
avet a burimprovementissoldwithinoneyear ofcomplation,for purpose of TOTAL:
builder will have the harden of proving thin he did not build or improve for purpose of
Sala.).
Cl I,aeownerofthepropry,amexclusivelyconoactingwithlicensMcmuecmreto QTY. PLUMBING PERMIT FEE F100D ZONE APN
construct the project(Sec.71144,Business and Professions Code:)The Contractor's
License Law does not apply tnanownerofpropay,whobulWsorimproves Hereon,and PERMIT ISSUANCE
wh vaintracts forsuchprojects wilhacontacmr(s)licensed pursuant lathe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far his reason BACK FLOW PROTECT.DEVICE UTSIDE
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF,AREA,COND. RECEfP1'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y—N
—
RECEIPT v
e of consent self-insure,oracenificate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a certified copy thereof(Sce.3800,Lab C.)which PARK FEE Y N
covets all e 1 (�#pder hy's p�ppy� GAS-EA.SYSTEM-7 INC.4 OUTLETS RECEIPf#
Policy# I%/q
BUILDING DIVISION FEES
Company Jb GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ CeNfied copy is hereby fumished.
fed copy is filed with the city inspection division. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe Permit is for ane hundred dollars IS IW) SE ITA EA,2001T. ENERGY ME
or less.)
I certify but in the performance mine work for which this permit is issued,lshall WATER HEATER W/VENT/ELECTR _
not employ any Person in any manner so as in become subject to the Workers' PAID
O .Z Compensation Lawxof Califnhim. Date WATER SYSTEM/TREATING Applicant pale Receipt#
NOTICE TO APPLICANT:If.after making this Certificate of.ETNion,yousM1 Id NEW RESIDENTIAL PLMB. SQ. TOTAL:
H zA become suhject to the Worker's Compensation provisions of the Labor Code,you ust
Ij forthwith comply with such Provisions or this pernit shall be deemed revoked. BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm Ihm there is a constructimn lending agency for the perfo ante of
�u — �E
U O the work for which the.permit is issued(See.3097,Civ.C.) TAL: ELECTRIC FEE
Landinex Name
Lender's Address - PLUMBING FEE
U QTY. MECHANICAL PEE MIT FEE
1 certify that 1 have read this application and state that the above in mtation is
cores.lagrcem comply with all city and county oNinencu and stem le rehomito PERMIT ISSUANCE MECHANICAL HE
f15 building construction,and hereby authorize representatives ofthis city to on ruponthe
U above-mentioned property for inspection purposes. ALTER O TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of CupeAn gainst
liabilitie gments.wsts and expenses which me me egad"'", - AIR HANDLING UNIT(TO Ig00fIC M)
in con a ce of the noting of dies p¢rtpiL
AIR HANDLING UNIT(OVER 10,000 CPM)
Stgnamre of ApphcangCommctor 7 Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE —'EATING UNIT(TO 100,00)BTU) Date Receipt#
Will the applicant or future building occupant store or handle huzardous material
as defined by the Cuportino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 110,000 BTU)
Coda Section 25532(a)4
0Yes o VENTILATION FAN(SINGLE RESID)
9BOILER-COMP(SHP OR 100,000 BTU) 9 EDATE
Will the applicanmrfuwre building occupant uuequipmrnmrdevices which emit n�ry asU6f�
hazardous ah contaminants as defined APR
by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r� 1995
_ / .
Ontario? BOILER
41�t� NEW RESIDENTIAL MECH. FUla
SQ.P
I have read he ha<ardeus ma-mils reremt
gwmes made,Chapters 95 of the h L'(Jj-Ntklll y(�
Califomia Health&Safety Code.Sections 25505,25533 and 25534. 1 understand Nat
ifthe building of currently have a tenant,that it is my responsibility to notify the `
occupant of e q ireme Is which must Its,met or to issuance of a Cemificate of
Ove, t
�YJ tai-9r-
Uwmef
A authorized agent Data TOTAL: ISSUED BY:
OFFIC