27775 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -- - PERMIT No.
APPLICATION/PERMIT
PLUMBING AL
ICA
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS:♦ 1 SANITARY NO. APPLICATIONSUBMfITALDA7E
UNIT# LOT#
_
OWNER PIRVE CON RACTORM? LZMNIC COM'ROLp
RClUTECDENGINEER: LIC NO: ADDRESS: I e— J r� El r
:S,710
CONTACT: PHONE: `i
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BO ELECT VMS me mOx
PERMIT IssuANce
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
PcwzOO I hereby affirmthnt l xm licensed under provisionaofChuptar9(commecause Eint
410{y0[ Section]undefDivisionlof tM1e Business anti Profession Codc end mylicense is in ppNBLg a��Y
Ftyzw full force and effect', �+-�r UP TO 200 AMPS
la, i_. sistita
FZm LicenseCe, ` � LIc.N�J��
F?y Dote Conwetor 201-I"AMPS SQ.FT.FLOOR AREA E/SQ.FT.
ZOyZ ARCHITECTS DECLARATION OVPR 1000 AMPS
OZ-0 I understand my plana shall be used u public recaNs.
Ft' W SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATIONSPECIAL CIRCUTDMISC.
�j0.a�O a F 1 hereby affirm that 1 um exempt from the Comonam s License Law for the
W3LLsn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
f� which requires a Permit o construct,alter,improve,demolish,or repair any income
':E prior to its issuance,also requires the applicant for such Permit ofile asigned aatcmem POWER DEVICE
pthat he is licensed putxuwno the provisions of the Cantrwmr'e Licenselaw(Chept
tr' 'el�y 9(commencing with Section 7000)of Division 3 of Ne Buxinexs and Prefessima Code) SWIMMIN LELECIRI VALUATION
ty'^y onhat he is exempt therefrom and the basis for the alleged exemption.Any violate.of OIITL -SWITCHES-Fl
F_ZQ Section 7031.5 by any applicant fore permit subjects the applicam 1.a civil PerWryof
!�yz$G nm more than five hundred dollsra($500). L E .
R p ❑ basownerofthepropeny,ormyemployeuwithwagesastheirwiecomp .tion, RFSmEMIAL; 5 Q FT. TI
STORIES TYPE CONSTRUCTION
4pt'1,3 willdothe work,and the structure is not intendedoroffered for sale(Sec.7044,Businas
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
employees,provided that such improvements are nothmendedoroflbred forsale.If. OCC.GROUP RES.UNITS
however,the building or improvement E sold withinane year Mcomplcticn,the owner- TOTAL:
holder wit[have the burden of proving that he did not build er improve for purpose of '
sale.).
❑ I,uowneruf Uepmiseny,mnexclusivelyconueciingwiUlicev contmetors o QTY. PLUMB ERMI FEE F1.00DZONE APN
construct the pmjwt(Sec.7044,Business and Professions Code:)The Contract 'a PERMIT Is
License Lawd snotapplytoanownerofpro Mwhobuildsorimprovesthereon, d
whomntmcteforsuchpmjcenwiUaconvactor(s)Iicertud pursuwuothe Contme rs ALTER-DRAT -WATEREA
License law. ) FEE SUMMARY
❑ I am exempt under Scc. ,B&P C for JEx m on BACK FL TELT. E UTSIDF.
SANITARY Y_N_
Owner Dam INS OR, O(W.AREA.GOND. RECEIPTIt
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby aff that l have a certificate,of consent o sel Ginsurc,or a certificate of RECEIPT#
wkers'Compemrsadon
Enormous or a candied copy thereof(Sm.380,Lab C.)which Fl -PER PARK FEE Y N
covers all employee's under this pemtit1 YSTEM-1 INC.4 0 S RECEIPT p
Policy# \ BUILDING DIVISION FEES
Company GA -EA. Y TEM-OVFR4(EA PLANCHECK FEE
El Certified copy is hereby famished.
❑ Certified copy is filed with the city impecdon division. GREA NDUSTRL WASTE RCEPTOR GRADING HE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE AP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is frroae hundreddollars SRXh SEWER-SA ARY- ORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfomwa of the work for which Chia Permit is issued,lshall WATER HEATER NENDELECTR
not amploy coy person in any rammer so as to beomme,subject to the Workers' PAID
Comperwtionlawsof California. Date WATER SYSTEM/IREATING Dam Receipt#
O Z Applicant
NOTICE TO APPLICANT:IL atter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F� N become subject to Ue Worker.Compenamon pruvisionaofthe labor Code, cat must
forthwith comply with such provisionu m this permit shall be deemed revoked. BUILDING EEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that ttim,is a construction lending agency for the Performance of
V O the work for which this permit is issued(Sm.3097.Civ.C.) ELECTRIC FEE
Lenders Nome
QF Landes Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) I ccnify that I have rai tipplicanom arm ante that the above infamadon is
correct. I agree to comply with all city and county ordinw< sodium,laws rehiring to PERMIT ISSUANCE MECHANICAL FEE
.Fr building concoction,and hereby.utharEac. senumivea this citymenter uporan, CONSTRUCTION TAX
L) mou,nemimed property for inspection purposes. ALTER OR ADD TO MECIi.
agree to save,indemnify and kee hurmine the ity of Cupertino against
liabil'nies, dgmems,costs cod in anyw accrue. 'r6rudd City AIR HANDLING UNIT(TO 1,1100 CFM)
in"nuque ce of the Brsotin of e
AIR HANDLING UNIT(OVER HLXO CFM)
Signnt of Appli Contractor Date EXHAUSTHOOD(WIDULT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hvardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(x)?
❑Yes VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Willthea Ii wmrfmurchuilJin equipmen BOILER-COMP(3HPOR 100,000 BTU)
pp gwcupantuse tmdeviceswhich emit
sea air comaninwts ox defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 1W,tMp BTU)
=.
11 Yes NEW RESIDENTIAL MECH. SQ.FT.
1 have read the ha>nrdom materials requirements under Chapter&95 of the
California Health&Safety Cede,Sections 25505,25533 and 25534. I understand that •,I/y,M1 9
i r the ccupabuildingothe res not currenmenta which
u must
lbs,e,that it r my responsibility of iry m notify the ^//
ocupam of the requirements which men be met prior m issuance of x Certificate of V
eeapanny. Y
Owneror tam.ival agent Date TOTAL: ISSUED BY: �
OFF