27348 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO1 :N.- .LLCI'RI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBNO-MECHANICAL 0 A O
BUILDING PROJECT IDEM 2 74 o IFICATION JJ
BUILDING ADDRESS: 4 SANITARY NO. APPLICATIONSUBMDTALDATE
2 I IL UNIT# LOT# 1
O E0.5 NAME: N PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
raw smu T O
CHITECIENGINEER: WC NO: ADDRESS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG R PLUMB MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DF.SCRI ON
QWz I hembyafOrm Nal lam licensed underprovisions of Chapmr9(commencing with
IY 00 Section]BIXB of Division 3 of she Business end Profession Cade,end my liana iii. PANELS V
cicdE full force and effect.
<yVg ty License Class Lic.M UPT0200AMPS
ti<y Date Contractor 201-Rod AMPS
ZOy?sARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0 I understand my plans shall be used as public recnNs.
�N ; SIGNS ELECTRICAL
i,
Licensed Professional
�I+IU OWNER-BUILDER DECLARATION SPECIAL CIRCUM/MISC.
�0 1 hereby affirm that 1.m exempt from the Contractors License Law far-the
Wit:It.
following reason.(Section J031.5,Business and Professions Code:Any Sisy orcounsy TEMP.METER OR POLE INST.
w.<4 which requires a permit to construct,alma improve,demolish,or repair any @bract.
Y7 prior to its issuance,alar,requires the applicant(orsuch permit to file o signedllnlemcnt POWER DEVICES
RO0pursuant that he is licensed pursuano the Provision of
the Convectors License Low(Chapter
deK 9(commencing with Section]IHI(fim Division 3 nfthe Business and Professions Code)I- . SWIMMING POOL ELECTRIC VALUATION
_r„ turbot he is exempt therefrom and the hands for the alleged exemption.My violation of'
�ZQ Section]031.5 by any upplicam Torn pemtit subjects the applicanno acivil penalty of OUTLETS;SWITCHES-FIXTURES
Sr�0
not more than five hundred dollars($500). NEW RESIDENTIAL ELECIR S .FT.
Sm ❑ 1,usownerofshepropcny,ormyemployeeswishwagnnsheirsolecompena.tion. Q STORIES TYPECONSTRUCTION
d will do the wmk.andtheawmure isnot intendWmaffenedfrraale(See.]Oa4,Buaiaess
and Professions Code:The Cmucclor's License Law Jas not apply to an owner of 'N
property whobuiWsorimproveatherton,andwhodoes such work idmwlfor throaghhis
tun employees,provided that such improvememaum not imendedoroffered(.ante.If, 'j OCC.GROUP 0.FS.0 ITS
however,she building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpox of
sale.).
❑ Lasownerofthe property,amesclusively contracting with licensed cansmem Q PLUMBINGPERMIT FEE FLOOD ZONE APN
construct the pmjccs(Seco]M4,Business and Professions CodeO The Cont tor'a fthflT ISSUANCE
License Lawdasnot applymanownerofprapeny,whobuildsaimproves th nand
who contracts for such projects withucontmcurn.)licensed pursuanO.rhe wmora pL R-GRAIN&VLN'T-WATER IPA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. B&P or INs maeoo OUTSIDE
B OW PROTECT.DEVICE SANITARY YN
Owner ° RAINS-FLOOR,ROOp,ARFA.COND. RECEIPT#
WORKMAN COMPENSATIO IARA � SCHOOL TAX Y N
Jo❑4 Ihcr<by affirm thntlhave acenificaa of nsennose ,,IRs rti f f9XTlIRES-PER TRAP RECLIPTM
, Comperainunlnsuranceoracenifi copy thereof(Sce. bC. PARK FEE Y N
coomi rill employee's under this permit. GAS-EA.$YSIEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company ssN s, W GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK HE
❑ Cer ilied eri,is hereby famished.
E] Comfiedcopyis Nedwith the city in,.\ ivision. GREASRpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATEOFEXEMPTIONFRO WORKERS' OREASETRAP SOILS FEE
COMPENSATION 1NSI/RAN
(Thissectianaednosbecamplete iftheNmsitisfor ch edddiscor($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in Ne performance of the work for which Nis permit is issued,I shall WATER PRATEER WNENT/ELECfR
not employ any person in any manner so as to become subject to she Workers PAID
Cr,mpenmtirn Lowsnf California. Date WATER SYSTENVIREATING Uele Receipt#
0 z Applicant
Z NOTICE TO APPLICANT:1Lafter mAir,this Ceni ficme of Exemption.you should NEW RESIDENTIAL PLMIL SQ.Ff. TOTAL:
r+ r/] become subject to the Wmkcrs Compensation provision of the labor Code,you most
forthwith comply with such provisions te this pernat shall he deemed revoked BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY. SEISMIC FEE
Uz I hereby affirm that there is a construction leading agency for the performance of TOTAL: ELECTRIC FEE
0 she work far which this permit is issued(Sec.3097,Civ.CJ
Leader's Name
Olender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have read this application and mute that the above information is
correct. I agree to comply with all city and county oninancw and store laws miming to PERMIT ISSUANCE MECHANICALFEE
Lo) building construction,andhcreby authorimtepresenmuves ofthis city venter upon the CONSTRUCTION TAX
V above-mentioned propeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupenino against
liabilisies,judgm ou"xadexpen hich yinany weyacerueagainassid City AIR HANDLING UNIT TO IRXXI CFM)
in cnnse.inpic c e granting of thi it.
'1 I AIR HANDLING UNIT(OVER 10,000 CFM)
Sirm0h,of AppiicanLTCrnMrectcrr Data EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO UK."BTU) Dasa Receipt If
Will the applicant or future building occupant store or handle hazardous material DEATING UNIT(OVER 100,(XgB
n defined by the Criterion,Municipal Cade,Chapter 9.12,and the Health and Safety TU)
Code,Sectio.25532(a)P
❑Yea 13 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP OHP OR 100,000 BT1J) ISSUANCE DATE
Will sbeapplicanmrfuwrcbuildingacupam useeyuipment ordevittawhichemit
fiaamdous air contaminanu n dTefined by the Bay Arca Air Quality Management BOILER-COW(OVER 100,000 BTU) {{�_ .4
Dimdct4
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read she harmonious mamrims requirements under Chapter 6.95 of the 1994
if the uBrngdoesa Health of etycur Code,tlyhav aImu5505at II is and 25534,1undenland that
Clry LuV a/`k
if the building does not currently have a tenant,that it is my responsibility ennotify the CITY occupant of the mquircmems which moat bo met prior to issuance of a CcrtificaR of
Occupancy.
Owner or amhorize]agent Data TOTAL: ISSUED OY:
OFFICE