26781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERkRTNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n p
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G O
BUILDING DDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
_
OWNERS E: PHONE: CONT CTOR'S NAME: LIC NO:
L 1, N/C CONTROLN
CHIT.CI' r GIN LIC NO: AD S: + /SGAA ❑
/ C',. . � s
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PER IT FEE
BLDG ELECT PLUMB . MECH
PERMIT ISSUANCE �1�1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RHSIDENTIAI. JOB EaZR
pyZ (hereby affirm CENSE licensed CONTRACTORvisDE LARA IO (wmmencing with L_-�-il`#,F�fl��"D=lsvl-`T
11-00 Section 7000)of Division 3 ofthe Business and Professions Cade,and my license is in PANELS
5UE full force and aEf(WsX�
p¢„Z License Class Lic.N - UPT0200AMPS
ti Z)y nate S( 4�canvacmr 201-1000 AMPS
Z Or`nxaa +_ eATCHITELTS DECLARgTIO OVER 1000AMPB SQ.FT.FLOOR AREA $/SQ.FT.
oz—C) I unhorsed my plans shall be used as public records.
r�nj SIGNS ELECTRICAL
9 yy�� .] Licensed Professional
L' Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.a4O i U 1 hereby effum chat 1 aot exempt from the Contractor's License Law for the
W'3OvFi followingreason.(Section 7031.5.Business and Professions Coda:My city memory TEMP.METER OR POLE MST,
on
rn which requires a Permit to construct,ellen improvedemolish,or repair any someone
prior m its issuance,alsnrequirestheapplicant for such vanm0o fileasignee atement POWER DEVICES
iy q O that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter
9(commercial with Section 7000)nf Division 3oftha Business and Pmfession3 Code) SWIMMINGPOOLELECTRIC VALUATION
or that he is exempt herefmm and the basis for the alleged exemption.Any violation of
F ¢ Section 7031.5 by any applicant for a Permit subjects the applicant to a Civil peOUTLETS lty
naof WXTURES
0 not more than fl.hundred dollars($500).
� w ❑ I,asownerofthepmperty,ormyemploymswithwagesestheirsolecompensaGm, NEW RESIDENTfALELECIR _SQ.PT. STORIES TYPECONSTRUCTION
y will do thework,and the structure isnotintended proffered foraale(Sce.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimproves thereon,and whodoes such warkhimselforthroughhis
ownemployees,pmvidedthmsuchimpmvementsaronotintendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyearefrompledon.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthe MNny,amaxclusivelycontraetingwimlicensedconvactomW QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project Saw.7044,Business and Professions Code:)The Connectors
License Law does not apply in an owner ofproperry who builds or improves thereon,and PERMIT ISSUANCE
whnwntracts forsuch projects with aconoacmbn licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
License Law.
111 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPTtl
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that l haves cenifiwte ofconsent to self-insms.aro wrtificareof FIXTURES-PER TRAP RECEIPT#
akeri Compensa[ionlnsuranceoracertifiedcopy thereof(Sw.3g00,LabCJwhich PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC. 0UTLETS RECEIPT#
Polly N BUILDING DIVISION FEES
Company
❑ Candied Copy IS hereby famished. GAS-EA.SYSTEM-OVER4 HIO PLANCHECK FEE
_
❑ Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need aatbe completedHthe permit is foronehundrM dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfortnmor of the work for which this permit is issued,l shall WATER HEATER W/V1t/MECTR
not employ any person in any.,so as to become subject to the Worker' PAID
z Compensation Lawsnf California. Date WATER SYSTEWMILTING
Applicant Date Receipttl
NOTICE TO APPLICANT:If,steer making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
V) becomesubject to the Workers Compensation provisions of the Labor Cafe,you must
forthwith comply with such provisions ar this pemdt shall be deemed revoked. BUILDING FEE
pw,a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7 z Ihereby affirm that there is a construction lending agency far the performance of
U O the work for which this pard[is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
LTa H Lender's Name
VLender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
CkI I certify that I have read this application and state that the above information is
cored I agree to comply with all city and county ordinances end state laws relating to PERMITISSUANCE MECHANICAL FEF.
tiLn building construction,and hereby authorize representatives of this city to enter upon the
U 7 above-mentioned propeny for laureation purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
rte- (Wa)agrq m save,indemnlf d keep harmless the City of Cupenlno against
Ilabilities,judgments,rou xpensu 'ch may in any wayaccraeagamitsaid City AIR HANDLING UNIT(TO 10,000 CFM)
wase soft gafthlspnm .
_ AIR HANDLING UNIT(OVER 10'"CFM)
StlasafflirFof ant/ ommctor - Data 00EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupenin,Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section Z 532(x)?
EI Yes 1:1 No VENTILATION FAN(SINGLE-RESHU
Will the applicantorbuilding occepby the
nBay equipmentQuality
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
dinner?imandkins air mnraminame as defined by the Bay Ams Air Quality Management BOILER-COW(OVER 100,000 BTU)
iartinr?
r ❑Yes 0 N NEW RESIDENTIAL MGCH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 end 25534. I understand(hat
if the building does not curmatly have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a CeniEcam of
Occupancy.
Owner or uathorized agent Data TAL: ISSUED B .
OFFICE