27243APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO..
ELEC rR ICA I
I PERMIT NO.
APPLICATION/PERMIT
PLUMBING - MECHANICAL.
27243
HULLOING DIVISION
BUILDING PR(JJECT IDEM"IIFICA'I'PON
BG ADDRESSS.S:r
SANITARY NO.
APPLICATIONSUBMITTALDATE
GILDING
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i v Oe/� I V
UNITN LOTH
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OVNGRSN E: CONTRACTOR'S NA LIC NO:
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N/C
CUM ROLIf
ARCHITECTENGINEER: LIC NO: ADD SS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DFSCRI ON
_
IherebYaffirm that l an licensed underprovisionsof Chapter9(commencingwiN
Section 7000) of Division 3 of the Business aw! Professions Code, and my license is in
PANELS
full force and effect.
LicerLuLlas Li )macs
0AMPS
�
Dme JO Con
201TOIOM
ARCHITECTS DECLARATION
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
I understand my plans shall be used as public m osols.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUFDMISC.
1 hereby affirm that 1 am exempt from the Contractor's License Low for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
which requires a permit to construct. alter, Improve, demolish, or repair my structure,
prior to its issuance. also requires the applicant for such Permit o file a signed statement
POWFA DEVICES
that he is licensed pursuant to the provisions of the Convectors License Low (Chapter
9(commencing with Section 7100) of Division J ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUAT0
antral he is exempt lhcrcfmm and the basis Por the alleged exemption. Anyvlmlationof
Section 7031.5 by any applicant Iia a permit subjects the applicant to a civil penalty of
OUTLETS - SWITCHES - FIXTURES
not more than live hundred dollars ($50E,
El 1, as owner ofilm property, or my employees with wages as thei r sale compensation,
NEW RESIDENTIAL ELECTR S.FT.
Q
'TOR
'TYPE CONSTRUCTIO
will do the work, and the structure is not intended or of for safe (Sec. Tod, Business
,
and Professions Com: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himselfor through his
-
VCC. GROUP
RES. UNITS
own mnployees, provided that such improvements are not i mended or offered for sale. If,
however. the building or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that Int did not build or Improve for purpose of
TOTAL:
❑ i, asownermf the property, amendusivelyrnmmning with licensed contractors to
L]
QTY. PLUMBING PERMIT PEE
FLOOD'%ONIi
APN
construct the project (Sec. 7114, Business and Professions Code) The Contractors
License Lawdoesnotapply m m ownerofpopsy who builds or improves thereon, and
PERMIT ISSUANCE
who contracts for such projects with a corrosions) licensed pursuant w the Conuamoes
Law.
ALTER WATER (EA)
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this reason
OUTSIDE FEES
BACK FLOW PROTECT. DEVICE
SANT YN
RECEIPT#
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX Y N
WORKMAN COMPENSATION DECLARATION
❑ Iherebyaffirm that l have a certificam ofcomentto self-insure.macenificateof
FlXTfIRFS-PER TRAP ��
RECEIPT#
PARKFEE Y N
Workers Compensation Insurance or a minified copy theamf(Sec. J8R,LabCJ which
covers all employee's under this permit.
GAS - EA. SYSTEM -1 INC. 40lI1LET5
RECEIPT#
BUILDING DIVISION FEES
Palmy p
Company
GAS - EA. SYSTEM -OVER 4 0E U
PLANCHECK REE
❑ Certified copy is hereby famished.
GRADING FEE
❑ Certified copy is filed with the city inspection division. GREASHANDUSTRLWASTEINTERCEPfOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
P.NERGY FEE
(This section need not be cemplmed tithe permit is for one hundred dollars (SIM) SEWER - SANITARY - STORM EA. 200FT.
or less.)
I certify that in the performance of the work for which this permit is issued, l shall WATER HEATER W/VENT/ELECTR
not employ y any mvmcr, s t t o the Workers
PAID
Com sof Calinarm are �a t `-r
WATERSYSTEM/IREATINO
Date Receipt#
NOTIC£TO APDL ANT: If, lemg ase of Ex<m� )lion, you should
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
become subject m Ne Workers Compensation provisions of the Lahr Code, you most
BUILDING IEE
forthwith comply with such previsions or this permit shall be deemed revoked.
4e „e,
SEISMIC IEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a commuctinn lending agency for the ptdomince of
fie work for which this permit is issued (Sm. 3097, Civ. CJ
T T L:!
13LEC1 RIC REE
Lender's Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING IR7C
1 sonify that I have read this application and state that the ida ve information is
MECHANICAL FEE.
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
building construction, and hereby uwhor is representatives of this city to enter upon the
CONSTRUCI'ION 'I'AX
uhovomctnioned popsy for inspection purposes.
ALTER OR ADD TO MECH.
(We) agree to save. Indemnify and keep harmless the City of Cupenino agaiml
liabi lines,judgments, costs and expenses which may, in any way accrue against said City
AIR HANDLING UNIJ'(10 10,0M CFM)
in comegWxse granting of it.
_
AIR HANDLING UNIT (OVER l0.0M CPM)
SwOrre plicanU untr. star .te EXHAUST fI00D (W/DUCI)
/
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO IROM BTU)
Date Receipt#
TOTAL:
Will the applicant or future building occupant store or hwdle hazardous material
as defined by the Cuprtino Municipal Code, Chapter 9.12, and the IleahM1 and Safety
HEATING UNIT (OVER IR,IXIO ETU)
��
Godo, Section25532(a)R
0Yes ❑ No VENTILATION FAN (SINGLE RESID)
vAycr:D
BOILER - COMP CHIP OR IR,f100 BTU)
Will theapplicantar future buildingoccupunluse<yuipmemordevices whichemit
hmallos, air contaminants as de inul by the Bay Area Air Quality Management
b661
Distrin?
BOILER - COME(OVER IR.ORBUD)
Te l�®
❑ Yes ❑ No
NEW RESIDENTIAL. MECH. SQ. FT.
I have reed the hazsrdous materials fequncermas under Chapmr 6.95 of the
Gov J
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand Nat
Y
if the building docs not currently have a tenant, that it is my responsibility to notify Ne
occupant of the requirements which must be met prim to issuance of a Certificate of
.
Occupancy.
ISSUED BY:
Owner tar emhorizN agent Date TOTAL:
OFFICE