27710 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I L A' PERMIT NO. O
APPLICATION/PERMIT PLUMBING
-MECHANICAL.
BUILDING DIVISION BUIL.DIN(;I'ROJECT IDRN'r[FIC'ATION
BUILDING ADDRESS: SANITARY NO. APPLICA'DON SUBMITTAL DATE
III ai LFop-n RI UE UNIT# LOT#
OWNS SNAME: 181k - P NU: CONTRACTOR'S NAME; WCNO:
pE7N/C CONTROL If
'IHTECf/ENGINEF,R: LIC NO: ADDRt S: ❑
CONTACT: PHONE: -
QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO.
BLDG ELECT PLUMB MECH
Q PERMITISSUANCE. ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDLNTNL LOB DFSCRIPf10N
uRpyz Iherebyaffirm shut l em Banaed arrimprovinum.faripler9(cammencingwith „T `�AE I!-�
Op Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS /T J IG e
pq� for]to.and effect UP T02W AMPS
<FZ License azs Lic.M_ p,
rn6y Dme/�Cmumtttr 201-I"AMPS
zON7�. ARCHITECTS DECLARATION OVER IOWAMPS SQ.F[„ LOOR AREA E/SQ.Irl'.
O2 O I undetstamd my plans shall ed used as public rtroof.. P'� peri , D
P oo l-W SIGNS ELECTRICAL O
Licensed Professional
.g herOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
E
yF 1 eby affirm that 1 am exempt from the Contractor's License Law for the 2Q
Ornfollowing reason,(Section 7031S,Business add professiorsCode:Aaycityarcounty TEMP.METER OR POLE INST. CITE 1996 -
M ur,us which requires u permit to construct,alter,improve,demolish,or repair any structure (J"
-M prior to itsissuance,also requires theupplicant for such permit to file.signed statement POWER DEVICES LVrC
y°fi p0 that he is licensed pursuanno the provisions of the Conuacm's License Law(Chapter /1//��
t1 p� 9(otnnamemg with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_y or thus he is emmpttherefrom and she basis fm the alleged exemption.Any violation of
Y Section 7031.5b Icer for itsub'ects the applicant to a civil alt of OUTLETS-SWITCHES-FIXTURES
[-2Q by Perm 1 pP Penalty
any 0
not mom than rofive hopro dollarmyem l NEW RESIDENTIALELECfR _SQ,FT. STORIES TYPECONSTRUCHON
e ❑ othe Wok.and the ture
wiffiendorsalei(Ste.compensation,
will dothewons C dthe he Comeactotimm�dnse Law
s not apply
7044.Business
and Professions Code:The Ca ducceda License ms does not apply to an owner of
poupcomenywhob,provirimprovesthempruve entsmesruch intwork cedormledforigh his OCCGROUP RES.UNITS
ownemployees,provdadthinsuch improvld wit arcnasi earmfdoroffered far sale eIf.
however ill the havethe urden mveomntisisot he diinotoeymr or impo efor flueowner. TOTAL:
builder will have the burden of proving thus he did not build or improve for purpose of
ale.).
❑ I,movencrofthe pmpeny,amexclusively contracting with licensed contractors to CT' PLUMBING PERMIT FEF; FLOOD ZONE APN
onstmet the project(Sec,7094,Business and Professions Code:)'no Contractor's PERMIT ISSUANCE
License Law doesnm.pply to an.onerofpropeny whobmIdsurimprovesthmmm,and
who comrams for such projects with a contmcmr.)licensed purrumtto the Convector s
License Law. ALTER-DRAIN&VENT-WATER(EA IEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fm this cessionO S D.
BACK FLOW PROTECT.DEVICE SANITARYY_N
Owner Date RECEIPT p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihcmbyaffirm thud l have a cenifteam ofconsent to selfinsure,or a certificate of RECEIPTp
PIXTURES-PER TRAP
Works a' employee'& nlnsurence or acedified copy thereo((Sec.7a0O,Lub CJ which PARK PEE Y N
Pavers all employeis undera this pectic 2�S�a1I� GAS-EA.SYSTEM-11NC.4 OUTLETS BUILDING DIVI
Paay SION FEB
nn —
y pony GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cerifted copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXP.MPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This sectiunneed not be compleled ifthe permit is for one hundred dollars($11110) SEWER-SANITARY-STORM EA.200fFT. ENERGY FEE
or less.)
I cenifyshat in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
am employ any perms in any manner so as to become object lm she Workers' PAID
Z C.on'timianluwsof Califomi., Data WATER SYSTHMfMFATING Dem Receipt If
Applicator
zO q NOTICE TO APPLICANT:It,after making this C,mfimm of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
!-� p?] lim m,minjecl 1. he Worker's Compensation provisions of the Lula.Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC ME
VZ 1 hereby affirm that there is a construction lending agency for the performance of
O the work for which this permit is issued(Sm.3097,Civ.C.) ELECTRIC FEE
Lender's Name `1 ' a
Leodefs Address QTY. . TEF. PLUMBING FEE
-� "MECHANICAL PERMIT .r
V I certify that I have read this application and state that the shove informutiun is "
correct.I agree to comply with all city and county ordinances end state laws relating to PERMIT ISSUANCE MECHANICAL FEB
V) buildimgermarruction,and hereby authrom representatives ofthis city toemerupon the I
CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agrte m mve,indemnify and keep harodeas she Cky of Cupertino against
liabilities,judgments,cosmandexprneea which may many way mcmeagamel mid City AIR HANDLING UNIT(TO I0,000 CFM)
inconsequene Imeggg{yyyWWWago f this tett
// ✓ AIR HANDLING UNIT(OVER IO,IXq CPM)
Sire of Applic tot/—� Dam EXHAUST HOOD(WNUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO[W.000 BTU) Dow Receipt#
Will the applicam or futtue building occupant store or handle hamrdotu material HEATING UNIT(OVF32IW,f100 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and she Ilealth and Safety
Code,Section 25532(ad?
11 Yes 11 No VENTILATION FAN(SINGLE RESID)
-
Will the applicum urfmurebuildingoccupam useequipmem ordeviccewhichemit
BOILER-COMP(3HP OR I W,WU BTU) ISSUANCE DATE
hamrdo s,air contaminants as defined by the Bay Arca Air QOallly ManagemHll
District? BOILER-COMP(OVC•R I W,ODp BTU)
13 Yes 0 N NEWRESIDENIALMECH. SQ.PT.
1 have mad the haatdous materiels requirements under Chapter 6.95 of the
California Health&Safety Cade,Sectfums 25505,25533 and 25534. 1 understand that
t i f the but lding does not currently have a mount.that it is my responsibility to nmi fy the
uccupenl of Nc reyuircments which muxt od tan prior m issuance of a Certificem of
Owupancy, oas�q
Owner or authorized agent Date TOTAL: ISSUED BY: V
OFFICE