28208 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .�
BDILUING EI.N.C'I'IalcA1. PDRMI I'NO, 28208^ �a^ /�
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING.MF.CHANWA', L ky.(7 L U�](l
BUILDING DIVISION BUILDING PROJECT IDEN'1'IFICATIOry
BUH.DINI/C/r$gEDDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/�� UNIT# LOT#
O RMF.. 0� Y'1�(NCOryTRACfOR' AME: ya CNO: NIC CONTROLM
CI{IITiCT/FNGINF.ER: LIrO NO: IDI'/^'FSS+• I�
wr
CONTACT: PHONE: BUILDING PC• O ELf:CTRIC PERMIT FF,EBLDG PLUMB MUCH
PERMIT ISSUANCE D
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION
P402 IherebyS17 Di Neel amlicense,dre,, stdPpmvraenium,,Code, (it mmendseI.Smnniz Sectionerebyaf Division 3elice Business and Prof,simns GNe,anJm encngwithpANE1.5
a W full force vnJ etT t.
Q UP TO 200 AMPS
Uz License C s 0 Lie.#
w M y Dam Conwmor 201-1000 AMPS SQ.FT.FLUOR AREA $/SQ.FP.
ZOo,Z ARCHITIZCT'S DECIAR ION OVER IOMIAMI'S
OZ—G Iundeman �Iws shellM mpubIt cba.
y WSIGNS ELECTRICAL.
Qad Jj Licensed Pms'fe tal
C G OWNER f UIiR DEC LAR ON SPECIAL CIRCUIT/MISC.
p,O per.F I hereby afOtm that 1 um empt from the Contractors License Law for the
1x+1 rn following reason.ISectimn9113 L5,Business and Professions Cade:Any city or c...ty TEMP.METER OR POLE INST.
t�"j which requires a permit toconswct,alter,improve,demolish.or repair any Structure
�R} prio .its issuance, requires theapplicant I...th pert.ftleaaignedmt
sement POWER DEVICES
at g'QO nmit that he is licensed pun
rsu:mo the provisions of the Contractors License Law(Chapter
46x0 ' 9(commenciaig with Section'1000)of Division 3 of the Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
Wim or that he is exempt Therefrom and the basis for the alleged exemption.Any violation of OIITLETSSWITCDES-FIXTURES
F Z G Section 9031.5 by any applicant for a permit subjects the applicantto v civil penalty of
� O
not more than five hundred Rollers($SW)' fia'jNEWRESIDENTiALELECIR _SQ.Ff. STORIES TYPE CONSTRUCTION
e ❑ Las.wsk,mul he
ismcmpioycd.,.fwagen...IUrsdec.mpensation,
will JothewnR,Crat: he Comianot'U License
Law
os raale(Se,to So Business
end Rofcssimna Craft:The C.mrvn.rs License Ism docs not apply t.w owner of
property whobuilds or improves thereon,and whodses such work himselfonhroughhia OCC.GROUP RES.UNITS
own employees,provided that such improvements are not i mendedor offered for su l e.If.
however,the building or improvement is sold within one yearofcompletion,the Owner.
builder will have the burden of proving that he did not build or improve for purpose of
aide.). QTY. PLUMBING PERMIT FEE
❑ 1,es.wnerof rM1epropeny,emexdusively ronvecting with littnser cunuecmrsm FLOOD ZONE APN
...Into the project(Sec.9(fi44,Business and Rofeasions Code:)The Convector's
License Law Jcesn.t apply t.w.wncrofproperry whohuildsorimproves @ercmn,and 'PERMIT ISS
whocenno.,tforsuch projectswiihacnnvaciods)Inensedpirsuare mthe Commemr's
License Law. qLT -DRAINffi VENT- A'fER(FA) FEESUMMARY
SIDE IT
EII am exempt under Sec. B&P C for this reason BACK FLOW 1'0.0I'13CT.DE G UT
SANITARY Y N
OwnerDv¢ DRAINS-FLOOR,ROOP,AREA, OND. RECEIP S
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
T hereby air'.that I have.canificatte role...a.,to self-matua,Drat icateuf FIXTURES-PER NAP RECEIPT'#
mkers'Compensalion Insurance or acenificd copy themo((See.3800, CJwhich PARK FEE Y N
oven all employee's under this permit. GAS- ' I 40 LCT, RECEIPT#
Policy# BUILDING DIVISION FEES
Company GA "TEM XORO PLANCHECK FEE
❑ Certified copy is hereby fucklatc.
❑ Cenifed copy is filed with the city inspection division. R' r N WASTE INTIiRCE GRADING FEE
CERTIFICATE OI'EXEMPTION FROM WORKERS431;13AS 'RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not M complete!Hthe permit is forms,hundred!idlers IW) SEWER-SANITARY-STQ EA.20BIT. ENERGY FEE
or less.)
I certify that in the perfonnwce.f me work]or which this permit is iuued,IS' I WATER HEATER W/V T/1?LECIR
not employ any person in any manner so as to become subject an the Worke. PAID
Comp,nsatim Lawsof Califamia. Data WATER SYSTIi EA'T'ING Dam Receipt#
O Z Applicant
C) NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESID TIAL PI,MB. SQ.ff. TOTAL:
!••' V] become subject to the Workers Compensation provisions of the Labor Code,you most
forthwith comply with such Provisions or this pram it shall be deemed revoker. BUILDING FEE
1 QSEISMIC HE
CONSTRUCTION LENDING AGENCY
z I hereby affirm tbauhem is a construction lending agency for performance of TOTAL: ELECTRIC FEC
U O the work far which this pemail is issued(See.3(197.Civ.C.)
Lander',Name PLUMBING FEE
V' Landers Address QTY. MECHANICAL PERMIT FBI?
O U 1 certify Omt I have read this application iad state that the above informelim is MECHANICAL PH
>, correct.l agree to comply with all city and county mlinwco and state laws relating to PERMI'PISSUANCE
F" N buddingommintction, it hereby malamizerepreseaimtives.f,hiS city to enter Upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECIL
(We)agree tat save,Indemndfy wd ke,p butmI St the City of Cupenino against
Iiabilitiea,judgments,c s Said espeneswhichen anywaya¢rueagainstswd City AIR HANDLING UNIT(TO IO,OWCFM)
inconsequencec 1 ranting afthl ermit.
AIR HANDLING UNIT(OVER IU(bO CFM)
Signature A icant/Cmnt PAID
or QE 1159 Asax {I D EXHAUST HOOD(W/DUCT)
11AZA0. OUS MATERIALS DISCLOSURE H&UTING UNIT(TO 100."BTU) Data Receiptp
Will the applicant or future building occupant store or Image hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? VENTILATION FAN(SINGLE RISID)
❑Yes ❑N. ISSUANCE DATE
Will he upplicantor future buildogmcupant use Nnyment ardevices whichemit BOILER-COMP(3HP OR 100,00(1 BTU) p� p
us air contaminants as deGndl by the Day Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A B
istrid?
❑Yes 0 N NEW RESIDENTIAL MECIL SQ.FI'. e
1 have mad the Safety
Code.
materials 5505,25533 under Chapter understand
.f the �V,V ZZ
California a alth revel&Safety CMe,Sections]5503,25533 and 255U.Ch I r6.95 tthe /s199
if the building does not currently have a tenant,that it is my mspsmsibility to notify the C//�
Occupant of the requirements which must M n
met prino issuance of a Certificate of U)-
VY�r 1
Occupancy.
Owner ter authnrized.gent Date TOTAL: ISSUED BY:
OFFICE