27274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY'
CITY OFCUPERTINO uaolNc-ELe RI AI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 27274
BUILDING ADDRESS:
r�^$ SANITARY NO. APPLICATION SUBMITTAL DATE
.O ,2 , 1 UNIT# LOT# 1 O
O RS NAMF.:��� PHONE: - CONTRACT R' NAME:
Lf 4j Dig N/C CON ROL#
ARCHITECT/GNGfNEGR: LIC NO: ADD S: ❑
?Aseftn- ST
CONTACT: PHONE: I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION gppL1ANCEs-RESIDENTIAL
pfZz Ihereby uffirn Nat l am licensed under provisions of Chapter 9(comme�dagwrita
inh �QI JO I
400 Section 9000)of Division 3 of Ne Business and Professions Code,and my le is PANELS L•
a� full force nn deffecr. ` T
.<Z Dole est Lick v �' F UPT0200 AMPS
mDN Dae Comram.r 201.1000 AMP,
7 FOy AR HITECTS DECLARATION OVERI "AMPS SQ,FT.FLOOR AREA $/,Q.IT.
oz-0 I un lcouund my plans shall be used as public records,
.l SIGNS ELECTRICAL
Licensed Professmonal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W 3 E 1 hereby affirm that I am exempt from the Contractors License Law for the
Q 4 following reason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
an 1 which requires n permit to construct,aper,improve,demolish,a repair any snuctute
G� prior to its issuance,also requires the applicant for such permit file a signed statement POWER DEVICES
04 p that he is licensed pursuant 0 the provisions of the Contactors License Law(Chapter
p0.' 9(commencing with Section 9000).1'Division 3 of Ne Businessand Professions Code) SWIMMING POOL ELECTRIC
an or Nat he is exempt menefromanl the basis for the alleged exemption,Any violation of VALUATION
4
Sol,. 703151, any applicant for a pernit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
G not moa Nen five M1undred dollars($500).
Ho 111,asownerOfNeprapmyormyempl0yeeswithwages nstheirsulecom on, NEW RESIDENTIALELECTR _SQ,n. STORIES TYPECONSTRUCDON
22 will rude work,and the sructum is not inerlido446
roffered for line
and Professions Code:The Contract.,',License Law does not apply m an owner of
ownproperty who bui Ids or improves Hereon,and who does ouch work hi msel f ed through his
emr,thees,p building
or lharlearmpis sold it in ne yetenfoomplfibmd firothe o dIr, OCC.GROUP RES.UNITS
however,the building ur improvement is he,tl within one year of completion,the owner-
b le.). will have the harden ufproving Ner he did not build or improve for purpose of OT
sale.).
❑ I,asowneruf Nepropeny,lmexclusivelycontactingwiNlicensedcuntractonto QTYPLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.7044,Business and Professions Cade)The Counumm's
License Law does not apply to an ownerofunteny who buildsor improves thereon,and PERMIT ISSUANCE
who contracts fursuch projects with a contractor s)licensed punuanuo the con milm's
License Law. ALTER-DRAIN&VENT A FEESUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason OUTSIDE FE S
BACK FLOW MOTE DEVICE
Owner SANITARY YN
Date DRAIN,-FLOOR, F,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y ry_
❑ Ihereby nffitm thalia..ce enifica.of c-nsenvo self-insure,-recenificem of FlXTURES-PE RAP RECEIPI'N
Workers'Co.penwtion Insurance oracerifmd copy there-f(See.3800,Lab C.)which PARK FEE Y ry
ors all employer's under this permit.
Policy# GAS-EA. TEM-I INC.40UT RECEIPT#T
Company BUILDING DIVISION FEES
O. 4 EA
13Cenifi W copy is hereby famished, GAS- SYSTEM- ( PLANCHECK FEE
❑ Certified copy is fled with the city inspection division, EASEAND RL EI RCE OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be computed ifthe permit is for one hundred dollars($100) SEWER-SANT -S
or less.) IT ENERGY PEG
Ice-By'hat in the perforator-fine wall far which this permit is issued,l shallW ERH TE /VEt1T'/ELE
of employ any person in any manner an as m become subject to the Workers PAID
z Compensation Laws-f Califomms. Dain EM NO Dole Reampt#
Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 4TIAL PLMB. SQ,FT.
V) become subject to the Worker's Compensation provisions ofthe Labor Code,you must TOTAL:
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
LTa ca CONSTRUCTION LENDING AGENCY SMSMICFEE
z I hereby affirm that them is u construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
LL. Lender's Name
O V Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state but the shove informafi-n is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
IzI buildingconstmction,and hereby aut mire representatives ofthis city to enter upon the
(, z above-mentioned properly far inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We) g.m save,indemnify and keep harmless the City of C doutgemand
h 'es,judgmenrs,enstsandexpe which. tent yec�r� ipys yt AIR HANDLING UNIT(TO 10,W0CFM)
cans
acres of Neu=`ng-fpe P�v L Io
W-� \�/Y ! {/ 1 AIR HANDLING UNIT(OVER 10,000 CFM)
Signe r of Appncnnr/Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO 100,000BTU) Date Receipt#
ill the applicarn-r future building-ccupanl start or handle hazard-us material
as defined by the Califirm Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOT
Code,Section 25532(a)7
11 yes CI No VENTILATION FAN(SINGLB RPSID)
Will the applicum0rfmure buildingoccupantuxeequipment ordevicee whichemit
BOILER-COMP CUP OR I1,000 BTU) ISSUANCE D
hazardous tit contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District,
❑141W Yes ❑No NEW RESIDENTIAL MECH. SQ.ET. q
I have read the hanzrdous materials requiamen[s under Chapter 6.95 of the Novlimania Health&Safety Code,Sections does 25505,25533 and 25534.1 understated that •V
if the building not currently have. that it is my responsibility to notify the Itl 0 ��
occupant of the requirements which must be met prior to issuance of a Certificate-f
Occupancy.
Owner-r eah0rzcal agent pare (/
TOTAL: ISSUED BY:
OFFICE