27120 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PI UIMHINO-MECHANICALPP.RMIT NO. 27120���O
BUILDING DIVISION APPLICATION/PERMIT
- BUILDING PROJECT IUIiN'1'IFI_CATION'
BUILDIN DDRES : SANITARY NO. APPLICATIONSUHMIITALDATE
N I LOTH MV V y
OWNE�'E: PHONE: CONT OR' NAM@ �V�e�IIGNO: V Y
N/C CON I ROL N
RCHITFCT/LNGINEER: LIC NO: AD ❑
CON PACT: PHONE: QT&.' ' `. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE � � El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB
mwz I hereby affirm that l ion licensed underpravisions of Chapter9(commencingwith TOR DESCRIPTION
1400 Smtioneand of Division 3 of the Business anti Professions Code,end my license is In PANELS ^` y
GLLl'" full force end effect.
U V UP TO 200 AMPS
LicenseClass Contractor
in a, Date Conlracmr 201 16W AMPS
F,z, ARCHITECTSDECLARATION OVER TWO AMPS SQ.FT.FLOOR ARG E/SQ.FU
OO ZO-G 1 understand my plans shall Ire used as public records.
SIGNS ELECTRICAL
� Q L'rcnadPofessionnl OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O d U 1 hereby a1Rrm Dat 1 am exempt from the Canlrucmr's License Law for the
1113 0.m following reason.(Section 7031.5,Business and Professions Code:Any any or county TEMP.METER OR NOTE INST.
to H O which requires u permit to wagoner,alley,improve,demolish,or repair any structure
to prior to its issuance,also requires the appllcanl for such permit o file a signed statement POWER DEVICES
W C O the[he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
0.O SWIMMING POOL.ELECTRIC
d o 9(commenoingwith erafro9andflfDivisifor of theed exemption.
Any iota Cale) VALUATION
ty,Yy orthm M1eisexempnherefmmund the basiafor[healleged exemption Any violation ofSecOUTLETS-SWITCHES-FIXTURES
a.,mn,how byu hundred dollar,
for.permit suMecw the applleammacivil penalty of
no[mare pan five hundred dollars(5500).
Q NEW RESIDENTIAL ELLCTR SQ.FT. STORIES TYPE.CONSTRUCTION
22 ❑ i,Joe wrk,afthepropeny,erm of adedsladmrdled sasthei(See 7044,Bsiadis
a whim,thewons anddh The Comstructure mune is License
Law does not
apply t oan Business
and Professions Code:The Contractors License l,uw does nil apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees.provided thatsachimprovements arenotintendedorafferedforsale.IL OCCAROUP RES.UNITS
however,the building or imprwvemenl is sold withinone yew ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale)' QTY. . PLUMBING PERMIT . ; FEE - FLOODZONE APE
E] I,as ownarofthc propenya xclnstvelywntraoting with bcen.ed contract to
,wrowt the project New.9044,Business and Professions Code:)The Contractor's "
Licensel.aw doesnn[apply to an ownemfpropcnywhobouds orimpmves thereon,and PERMIT ISSUANCE
whowmrects fin-such projects with awnructor(s)licensed pursuant tothe Contractor's ALTER-DRAIN&VENT-WATER(CA)
License Law. '.FEE SUMMARY
❑ I and exempt under Sec. B&P C for this reason BACK FLO W PROTECT.DEVICE, OUTSID.PEPS
TARY Y N
Owner Date RECEIPT#
DRAINS-PLOOR,ROOF,AREA, ND.
WORKMAN COMPENSATION DECLARATION SCH LTAX YN
❑ IhereM1y affirm that lhavm certificate treatment to self-insure,oro certificate of FIXTURES-PER TRAP RECEIPI'k
'Workwm'Compemsation Insurancermit. ifiW copy thaenf(Sec.3B00,Lab C)which a PARK41, Y N
rsaliemployee's under this permit. GAS-EA.SYSTIiN i .4 OUTLETS RHCEIPT Is-
ISION
Policy N BUILDING DIVISION PERS
Company GAS-EA.SYSTP -OVER4(EA) i PLAN C CK FEE
❑ Certified copy is hereby Outwitted.
❑
Certified copy is filed with the city inspection division. GREASB/IN STRLWASIVW C R GRA LNG PEE,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE AT SO SFEE
COMPENSATION INSURANCE
Has section need not becompleted ifthe permit is parent,hundred dollars($100) SEWER- NITARY .20 FT. GRGY FEE
or less.)
I cenify that in the performance ofthe work Por-which this permit is issued,I shall WATER 1113AT!�WA/EsFp/ELECAJ
not employ any person in any manner so as m become subject to the Workers' PAID
Compensation Laws of Califomiu. Date WATERSYSTENUTR TING Dote Receipt If
O Z Applleaa
0-. O NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB .FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Cale,you must
forthwith comply with such provisions wills permit shall be deemed revoked. BUILDING FEE
C1a SEISMIC ME
FEE
CONSTRUCTION LENDING AGENCY
ZI hereby affirm that there is a construction lending agency for the performance of
O
be work for which this perrml is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE Q.
.
Lander's Name
LL F^ Lenders Address QTY.�";s MECHANICAL PERMIT hgg PLUMBING ME
U I Germy that I have read this application and state that One above information is z "' """' MECHANICAL.FEE
wnea.l agree mcomply with all city and roomy ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authmin representatives ofthis city menter upon the
CONSTRUCTION TAX
U Zwon,(mentioned progeny for inspection purposes. AL'T'ER OR ADD TO MECH.
I
(We)agree nt sax,andexper and keep harmless the City of Cupertino against
Iia It'Bics,Judgmems,a is andexpenses which may in anyway accrues stoat said City AIR HANDLING UNIT(TO 10,000 CEM)
in cons¢ nee of the mimgofthispermit.
Q / AIR HANDLING UNIT(OVER FLOW CEM)
S' a sof AppimiuF m[ractor V ate EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HHAM O UNIT(TO 100,000 BTU) Date Receipt N
Will the applicant or future building occupant emrc or handle hazardous materiel RELATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by 0o Capenfn.Mumeipal Cade,Chapter 9.12,and the Health and Safety
Code,Swtion 25532(u)'1 VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSLJ NCEDATE
Will Iheapplicanrfuturebuildingoccupant use equipmentordevices whichemit
BOILE,R-COMP(3IIP OR IW,fpO BTU)
w
I hazardous air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER light IB BTU)
Dlsriet' CT -6
199 Innn
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 4
1 have read the hazardouse,materiels 5505,25533 under Chapter 695 of the e//r Vr
Hard
Health&Safety Code,have
a to 25505,25533 mud responsibility
I understand Ihm V(Irl.PII(pq
if[ho building does not currently have a tenant,that h Is my responslbiliry[n modify the
occupant of the ruryiremems which must be met prier to issuance of o Cenificma of
Occupancy.
Owner nr authorized agent Date TOTAL: ISSUED BY'
OFFICE