27871 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO hasn"Dllux-b FC I ,RICA PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECT I)KN'OVLCATION 27871
BUILDINGADIIRESS: SANI'T'ARY NO. APPLICATIONSUBMTITALDATE
UNIT# LOT# Itel,
I OWNHt5.4AME: PHONE:_ CONTRACTOR'S NAME: LIC NO: L
N/C7 CON]SOL x
ARCI GI I Mi LIC O: ADDRESS: ❑
7011 ACT: ! PHONE: QTY. ELECTRIC PERMIT FEE. BUILDING,PERMIT INFO
c-ra91 / 3 7V-?(11Y3 PERMIT ISSUANCE BLDG ELECT PLUM MECH
LICENSED CON'I'RAM OWS DECLARA'DON APPLIANCES-RESIDENTIAL JOB UESCHIPI'ION
ozz I hereby affirm that l am licensed underpmvisionsofChapter9(commsC `�each,with C>� ,_. �`
u100 Section Man of Division 3 oldie Business and Prmfeselons Code,and my license is in PANELS
L�� f�\J
FFV F full force and effect.
q-- 4
E—Ga License Class Lie.# UP TO 200 AMPS
c,<y W Date Contractor 201-IOAMS
z ONZZ ARCHITECTS DECLARATION OVER IOW AMPS SQ.FI'.FLOOR AREA $/SQ.FT.
Oz—t] I understand my plans slid[be used us public retorts.
545W SIGNS FLECENCAL
, Licar ed Professional
�Cee< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaF I hereby affirm that 1 am exempt from the Contractors License law for the -
n1,3 tr.m following mason.(Section 7031.5,Business and Professions Code;Any city or county TEMP.METER OR POLE INST.
u'O l which requires a P[.i,ro mnstrum,me,improve,demolish,or repair any stracmre
AW>2 to its issuance,also m the applicant for such Pamir to file a signedswtemcm POWER DEVICES
prior quires pp peLa
�z�p that he is licensed Pursuanno he provisions of the Canwmnrs License Law(Chepder
d0.o 9(commencing w ith Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_to or that he is exempt rhercfrom and the funis for the alleged exemption.Any violation of OUTLETSSWITCIiLS-FIXTURES
1.. > Stenon 0031.5 by any applicant for a permit subjects the applicant -
o a civil penalty of
k�^� < net more than If,.hundred dollars($500).
Wro ❑ Lasownerofthe propeny,mroyemployees with wagesm theirseleconi'msmion, NEWRFSIDENTIALELECTR _S .IT. STORIES TYPE CONSTRUCTION
yam will(to(be work,and the sweturo is not intended or offered for sale(See. Business
and Professions Code:The Contractors Liana Law does not apply m an owner of ,
pmperty whobstokbor impoweanw,ma and who dmeeauch wnrkhimselfor thmughhis OCC GROUT' RES.UNITS
own employees,provided that such improvements am not intended or offered formle.If.
howeveq the building nrimprovement is sNe within one year of completion,theowner- TOTAL;
builder will have the burden of proving that he did nor build m improve for puryme of
olc.J.
❑ I,asmwnerofthepmpony.amexcmaivelyeo imciingwimuemsedeomnaonm QTY. PLUMBING MIT FEEe.00O ZONIi APN
construct the project(See.7(".Business and Professions Cale:)The Comant.",
Limn,Lawdestaii ply mmowneref,doperty,whobiildrorim,roves thereon,and PF:RMI'f 155UAN
whocoaracta lorsuch projects with a commemrad licensed pursuant o the Contractor's gLTli AIN&VENT.WATER(PA
Liodas,Law. 7 SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason BACK MOW PROTECT.DEVICIi SANITARY Y OUTSIDEFEES E N
Owner Date HGCI3IPP p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION 'SCHOO1 X Y_ECIi1PT# N
❑ Ihcreby affirm that l have a certificate ofmmu
eno self-insum,on ttnifcate of XTURFS-PER TRAP R
Worker'Compassarion Insurance ma oenified copyrhureof(Sm.SSW,Lah CJwbich AH ;E - Y_N
rs all anplayre's undenhis pesmih
RECHlPT#
GA EA.SYSTIiM-I IN O EI'
Policy# BUILDING DIVISION FEES
.Company GAS- .SYSTEM-OV 4 LANCHECK EEE
❑ Cenifen e.,m hereby f eranhed. 01 ,
❑ Cenifed copy is fled with the city inspection Division. GRFASW USTRL WASTE I RCEPTOR N1 GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEMA SOILS FEE
COMPENSATION INSURANCE
(This section need not It completed ifthe permit is for one hundred dollars(SIM) SEWER.SANITA -St'ORM ISA.200FT. ENERGY FEE
Id".)
I terrify Nm in the perfmcamec.flm,work forwhichrhispantan Ts issue,I0u11 WATER HHATER W/ /ELFCTR
nn
not employ any person in my maer so as m become subject to the Worked PAID
Compemarionlawsof Califnmia. Date WAT'I3RSYSTEM(TRIATI Dore Rrecip,#
0 Z Applicant
z0 NOTICE TO APPLICANT:If,after making this Carnficam of Exemption,you should NEW RES I DE11 IAL PLM Ii, SQ.IT. TOTAL:
t+ become subject to the Worker's Compensation provisions of the labor Code,you must
(k 7 forthwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE
C, CONST RUCTION LENDING AGENCY SEISM IC FEE
U z 1 hereby afford that there is a construction lending agency for the performance of
the work for which this Penni,is i....d(Sec.3097,Civ.C.) TOTAL: ELECTR IC ME
0 lender's Name
0 H lenders Address - QTY. MF,CI IANICAL PERMIT FEE PLUMING FEE
V 1 certify that I have read Nis application and state that the above information is
�" Da
correct.l agree mconlply with all city and county ordinancesand state laws baladingm PERMIT ISSUANCE MECHANICAL FEF.
f—' building emmrramion,and herebyattlamm represenrmivesmthmen,to cmnupon the
V above-memimed dr any for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and kap harmless the City of Cottoned against
liabilities,iutlgmcnts.coam and expenses which may,in any wayaccrue against said City AIR HANDLING UNIT(TO HL"CFM)
inco2tonscoftheghaning this it.
AIR HANDLING UNIT(OVER 10,000 CFM) y
mmre of Ap m/C mmcmr A ate EXHAUSI'HOOD(W/DUCq I�4
PAID I_r 1r2
HAZARDOUS MATERIALS DISCLOSURE HEATING UNH'(TO 100,1X10 BTU) Date R
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVfR IN)."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CMe,Section 255J2(a)R ❑No
El Yes VENTILATION FAN(SINGLE RBSID)
.
UCE DATE
Will the applicantarfuturebuildingoccupanruse equipmenrordevices whichemid
BOILL•H.COMI'(3E{P OR IW.INg)BTU) ISSA
hazardous air cormainums Its defined by the Bay Area Air Quality Manngenant
District? BOILER-COMP(OVER IIp,IX10 B'fU)❑Ycv 1:1TI
No NEW RESIDENAL MSCI I. SQ.R. P A I:
I have mad the IncoSafety
C our materials 5505,m,mm25533 under Chapter G.95 of the ��� � �
Cel c hold irg du s Safety Code,Sections 25505.25533 mJ 25514. 1 underhand Net
ifthebuildingencsnw currentlyhaveatecta,,that it is my responsibility modify the
occupant of the mquiremems which mus be mer Orion to issuance ofu Cmifcam of
Occupancy: r
WU
Owner or nmhnrized agent Data TOTAL: ISSUED BY: