27058APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO l L JL J n r1�1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
"; BUILDING PROJECTIUENTIWCATIONsg,i;-s:iis,
FERMI I NO.
27058
BUILDING ADDRESS: //++�A
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SANITARY NO.
APPLICATION SUBMIMDTALDATE
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WNPRS NAME: / /� PHb 47 ONE w
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C \ OR:S NAME' LIC NO:
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.�,RCHITECDTNGINEER: LIC NO:
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CONTACT: PHONE:
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ELECT PLUMB
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I PERMIT ISSUANCE 2'
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LICENSED CONTRA(7fOR'S DECLARATION
Iherebv affirm mat l um limnsedunder provisionsof CM1apter9(rommencingwith
Section ]IXq)ofD for Businessond Professions Code,and no lRense is in
instars.
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
;zyfull
fuse he
Avec. qc
UP T020o AMPS
201-I"AMPS
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A CHITECI-S DECLARATION
1 undersand my plain shall It lived as public records.
OVER I 0 AMPS
SQ. FT. FLOOR ARRA
S/SQ. FT.
SIGNS ELECTRICAL
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Licensed Professional
OWNER -BUILDER DECLARATION
I numb, affirm that I am exempt from me Convaltms License law far the
following reason. (Section 7031.5, Business and Professions Code: Any city orcaanty
molish. or repair any suu
which parodies a permit to construct, alter, improve, deunpa
priormiu issuance. also Termor, me applicant forsuch permino filen signed statement
mat he is Imensedpursuannn me provisions of the Contractor's License Law (Chapter
9fcommmacing with Section 7") ofDivision 3 addle Business and Professions Code)
or mat he is exempt merefrom and the basis for the alleged eecmption. Any violation of
y any app icon ,,rind so 'cc pp scan Pena y o
Section 703156 I tfora t subjects the I no a Civil h f
not mom than rivehundred
M.ordollar(SSm).
comperemton,
❑ Lshe wrk.andcesomeo,ormy<mpindedor offend for
will dome wad. and the structure is not intended (Sec. 7044. Business
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEN' RFSIDENTIAT.ELECfR _SQ. FT.
STORIES
TYPE CONSTRUCTION
oro Calc: The Cont , Law does not
and Pr License Law dos not apply lf rt owner
y who errors iof
s
owncrtywices.pdsorimprosuchimonandwhodocssuch work tended lmulforthrough his
cmc ided mut improvemwithin n do ole If.
ear
OCC. GROUP
RES. UNITS
.y
vera plebe ,for
is soil within in of build of completion, me owns-
& building e of
huweva, me ase meg Orden of proving
builder will base the burden of proving mm he did not build of improve for purpose of
r e n ,•' a -r a .. oar nY sTz.' R,
�5% .-' s-�r�.FEE T'
QTY 'PLUMBING PERMIT• is
-;nr ,t,xs 5 R
salc.l
mlansd convact
❑ Laz uaect
FLOOD ZONE
APN
iu.704,am Business and Prtrzssions .....y,}vyk.,y.�t,,ar
Lim. wi project (Sec. 7044, Business and Profusions CodmO Tee Convenor's
cls imtualbe
PERMIT ISSUANCE
prim
who contmns forsuch projects with aconuaaor(s) licensed pursuant m the Convenor's
whomdawdo,snon ,blonymi with. ommuct licensed Contractor
Lim. Law.
ALTER- DRAIN X VENT- WATER (FA)
❑ I am exempt under Scc. . B & P C !m tNs mown
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT
-r'
�-'covers
Owner Date
DRAINS - FLOOR, EA, COND.
WORIOdAN COMPENSATION DECLARATION
❑ Ihcmb, effiren that l have a cenificam of consent to sc.f-insure. or a certificate of
Workers Compensation Insurance or a certified copy thertaf(Ses. 3800. Lab C.) which
all employee's under this permit.G
PMicv#
SCHOOL TAX YN
RECEIPT#
FIXTU -PER TRAP
PARK FEE Y N
RECEIPT#
-EA. SYSIT f-1 INC 40UTLET
BUILDING DIVISION FEES
Cmnpan)
AS - EA: VER 41
PLANCHECK FEE
❑ Certified cop, is hereby famished.
ClCenifid ropym filed with me city inspection division.
GREAS TRI.W UfTERCEPTO
GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS'
,TRAP
SOILS FEE
COMPENSATION D SURANCE
R - S -STORM EA _fMET.
ENERGY FEE
(This vecdan need nm Im completed ifdle permit is former hundred dollars(SIM)
m less.)
WA HEATER W/VEnT CTR
Icenif, that in she perforance of me work for which oris permit is issued, l shall
an, employ any person In any m , so az mo become subject m the Workers
anDam
PAID
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0
Comperamon Lawsof California.
Applicam
NOTICE TO APPLICANT: If ager making oris CeniEcme of Exemption. you should
TER SYSTEMM NG
Ole Receipts
NEW RESIDEN PLMB. SQ. FT.
TOTAL:
7)
5
became subjm t to me Worked. Compensation provisions of the Inbar Code, you must
f imbwith campy with such provisions m this permit shall be deemed revoked.
BUILDING HE
SEISMICFEE
CONSTRUCTION LENDING AGENCY
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pang agency pe
I hereby affirm mat there s a consvucton lend' for the performance f
gra work for which this .it is issued (Sec. 3097. Cis. C.)
Lenders Name
TOTAL
ELECTRIC FEE
QTY Vii;;'+MECHAMCAL PERMIT �.rR.�s FEE^,(3°?s
``•- -zya• sx.:... r.xer.. s.� ;dxf ?st$. ! .n:. s . *.a-,
PLUMBING FEE
ianaersnddreas
1 CemfsF mm 1 have read grit it,licaion and nam that me above information is
Tract..ague, to comply with all cim and county ardinances and stem laws palating to
building construction, and herhv aathroce representatives of this city o, enter upontb,
above-mentiond pmpeny far inspersion purposes.
'^
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MBCH.
CONSTRUMHONTAX
-�
(We) agar w save, indemnify keep harMess the City or Cupertino against
liabilities,judgmcna. sa andex s which may in any utaJ'a rueagainst Fid City
AIR HANDLE NG UNIT (TO 10.W0 CFM)
AIR HANDLING UNIT (OVER Io.IXIB CFM)
nseq , of "4 momng a i"permi /J
PAID
�/( ('
EXHAUST HOOD (W/DOCT1
Signature of Appllean/Comucor ate
HEATING UNI 'T(TO IMMO BTU)
HAZARDOUS MATERIALS DISCLOSURE
Oat Receipt#
HEATING UNIT (OVER 100,000 BTU)
T
Will the applicant or future building occupant store or handle hare rdoos material
lie def ned by ihm Cupcnina Municipal Cde. Chapter 9.12, and the Health and Safety
VE1,MLATION FAN (SINGLE RESIDE
Code. Section 25532(.)?
❑lbs 0 N
ISSUANCE DATE
.
Will thea licanmr future buildin mxe tnrdevices whichamt
rr Eby qea
BOILER- COMP (311P OR IW,000 BTUI
BOILER -COMP(OVER I00.000 BTUI
the Air
M1uzurdoun air umwminums at defined by gra Ray Arca Air Quality Management
Diarict?
NEW RESIDENTIAL NIECE]. SQ. Ff.
❑ Yes ❑ No
Sf p Gl
I ha., lead paha moriolout materials miBimemats ander Chapter 695 of the
1 �5�4
Culimair. Health ec Safe,, Coda Sections 25505, 25533 laid 25534. 1 understand that
if the build.., does ned cl rently have. tenant. thrum ., in, re,olm,ibihoy to notify the
occupant of the requirements which must be met prior m issuance of a Cenifica¢ of
Oecti ane..
ISSUED BY:
Owner or aumho and agent Date
TOTAL:
OFFICE