25931 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ' >�A, PERMIT No, w (]
APPLICATION/PERMIT PLUMBIN0.MECHANICALMECHANICALBUILDING DIVISION 1 �7
BUILDING PROJECT IDENTIFICATION
BUILDING ADDR1♦E_SS`� SANITARY NO. APPLICATIONSUBMITTALDATF:
LOT#
O IiR A G: PHONE .yam CONfRACfOR'SHAME: N Ab
N/C CONTROL#
ARC IIiC1'/ENGINL'IiR: LIC NO: ADORE
O. wC 3 y
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
_ BLDG ELECT PLUMB MECH
• PERMIT ISSUANCE rA. El 11 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL s�-� N TOB DESCRIPTION
py�y Ihereby affirm that l am licensed underprovisionsof Chapter9(commencingwith
µA00 fall( ejaidof Divisiun3 ofthe Business and Professions Code,end my limns in in PANELS •"�"^' l
<V full.o,Candcffca UP TO 200 AMPS `r
aZz,W License Class Lic.p
hay Date Comrectm 201.1000 AMPS
ZOy'z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.IR.
O Z'"M 1 understand my plans shell be used as public records.
f-y�; SIGNS ELECTRICAL
Licensed pndessional
K a'< OWNL'R-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
aOaU 1 hereby affirm thin 1 an exempt from the Contractors License Law for the
1 3a,F„ following remun.(Sectinn]OILS.Business mdPmfessiom Code:Any city mcoumy TEMP.METER OR POLE MST.
1.' O which requires a Permit to construct,alta,improve,demolish,or repvr any strunurc _
f }�, prior to in iouince..k.requires theapplicant hasuch pemut to file a signednnemem POWER DEVICES
WK<Om that he is licensed pursuant to the provisions lithe Communes License Law(Chapter
dkeLL 9(commencing with Section]000)of Division 3of the Basin.,end professions Cade) SWIMMING POOL ELECTRIC ` VALUA11Q
W w— .,that he isexenno merefromund the basis for the alleged exemption.Any violation of OUTLETS l�O C-
�z,a
Section 7031.5 by myappliesmfar a permit subjects the Wheam m - -
a civil purely of I
04O nm murethan five hundred dollars(S50E. NEW RESIDENTIAL ELS
❑ I.mawnerofthepmpeay,ormyempl.yeeswithwagesaftirmlecompemrti.n , fY STORIFS TYPECONSTRUCTION
a3— will do the work,radio,structure is not inundedor.ffned for We yee.]OG4,Bust... N
and Professions Code:The Comments License Law does not apply to an owner ofr
property whobuildsorimprovesihemon,and whodoessuchworkMmxlfordbou gh his
own employees,ldoger ohm suchrmprovementhin ne ourdedonpletin.the owner.
C.GROUP RES.UNITS
howeer ,will ionthngmden of,mentishat sold he idnoneyem ofc prove for theowncn T
builder will hove the burden of,moving that he did not build or improve for purpose of DA
.).
❑ Las ownendthe property,am exclusively convecting with licensed contractors t. QfY. PLUMBING PERMIT F;, FLo�oP ZONE nPN
instruct the project(Sec.7044,3miness and Professions Code:)The Customer's PERMIT ISSUANCE
License lawdoes not applytu mowncrofpropany whobuiIds or improves thereon,and
whocontmns for such projects with accountants)licensed proment to the Character, ALTER EA
License Law. ( ) FEESUMMARY
❑ I am exempt under Sea ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE PRO
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I herebyaffirm that l hoveacvnificateofconxm mself-imme,oracMiGcme.f RECEIPT#
Workers'Curpen.rtion Insurance or acenified copy thereof(Ser.3800,lab C.)which FIXTURES-PER TRAP PARK FEE Y N
coven dl employee's under this Permit. GAS-EA.SYSTI INC, OUTLETS � RECEIPT#
Policy# EM- BUILDING DIVISION FEES
Company GAS-RA,SYSTEM-OVER 4(EA) PLANCHFCK FEE
❑ Ccnified copy is hereby furnished.
❑ Certified copy is filed with the city inspected division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FAEMPTION FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(This section neednm becompleted ifdmpermit is for one hundred dolhn(SI00) SEWER-SANITARY-STORM EA.20lIFT. ENERGY FEE
or mo.)
I certify thin in the Performance of the work for which Ms Permit is issued,I shell WATER HEATER WNENWELECTR
nut employ any person in any mmner so as to become subject uh the Workers' PAID
O z
Compensation Lows.(Califmmia. Date WATER SYSTEM/TREATING Date Receipt#
NOTICE TO APPLICANT:IL after makingthis Certificate of Exemption TOTAL:
pion,you should NEW RESIDENTIAL PLMB. SQ.FT.
H Vj become subject to the Workers Compensation provisions of the Labor Code,you run
a ; forthwith comply with such provision.or this permit shall he deereed revoked. BUILDING WE tz
r•
ped- Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for Nm
e Performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.LN],Civ.C.)
P Lender's Name v PLUMBING FEE
0Lenders Address QTY. MECHANICAL PERMIT FEE
U 1 certify that 1 have read this rppLcuion and are that use above information is
correct.lagreetu comply withell city and co only crommnces andante laws relating to PERMIT ISSUANCE MECHANICAL FEE
D,,, builiingeonswction.and hereby authotu rtprtsenutivcs of Wsciry tocmecupm Ne
U Z above-mentioned pmpeny for inspection purposes. ALTEH. CONSTRUCf10N TAXRORADDTOMEC
(We)agree to save,indemnify and kap ha dmos the City of Copeman.against
I'm IiIin,juit nu.cosa sndeapenxa whkh may in my way me sums.mid City A IR HANDLING UNIT GO 10,000 CPM)
in cnnsey he grmting ofNis mitt.
AIR HANDLING UNIT(OVER 10.00 CFM)
nature. pplicam/Com nnr Dam EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS h TERIALS DISCLOSURE
GRATING UNIT(T0100,000 BTU) Dau Receipt#
Will the the Criteorfuroreicipal ng.ccupamstoreor and a Health asd Safety
as AcEnnl by We Cnpcninn Municipal Coda Chapter 9.12,and the Health mJ Safety IIEA'T1NG UNIT LOVER I00,000 BTU) 'fOTAD.
Code,Seen i25532m)'t -
. ❑Ycx 1:1 No VENTILATION PAN(SINGLE RISID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUAQinN�rE WA�E
Will the upplicmmrluturcbuildingwcupmtoxequipmenwrdeviceswhichedth P
�humrdom air conmminams as defined by t .Day Area Air Quality Management
District? 1 BOILER-COMP(OVER 100,000 BTU) pp�
❑Yes CI No NEW RESIDENTIAL MECH.—SQ.FT. Fan 1994
1 have read the hazardous numtials requirements under Chapter 6.95 of the F �'�1 �t 1JJ`P
California Health&Safety Code.Sections 25505,M533 and 25534. 1 understand that 1
occupant
of
he sesnmcunemlyhh must is thin.is mymanceiofa C ifiru the Vurtnl/ H
Occup an of the requirtmema whish run be run prior to issuance of a CcniGvam of
Occupancy.
Owner m omhotixed agent Data TOTAL: ISSUED BY:
OFFICE