27658APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDINL-ELE IRICAI.
APPLICATION/PERMIT PLUMBING- RMECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEnFICATION
PERMIT NO.
n % [x C Q
G I O J v
BUILDING IbG �
SANITARY NO.
APP1LICam% SUBMHTAEDA'11
UNIT as LOT at
nil
•—�
O P NAME: H ^
4jtjt
CONTR OR'SM' LICN
14
NIC
El
CONTRDLX
ARCI 11TECUESM (NEER: LICN(
ADDRESS
��
CONTACT: PHONE :
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CtI
PERMIT ISSUANCE
ssit11 ❑
LICENSED IsiDCON7iander,mvid.CLARATION
I hereby affirm0m1emliCONI under RAM OR'S ECLATapter9(commencingwith
Sation )IXq)o 3 the Business and Professions Cale. and mylic<nu is in
pPl'LIANCES- Rli$IDEMTIAL
PANELS
_ fOIl OESCR
full force and t
a �LIC,X
Licenx Class
UP T0200 AMPS
201-I(Mq AMPS
Dine fmCTSD
III TECPS UIiC1.ARATION
SQ. PT. 17LMR AREA
$/SQ. Ef.
OVER IUM AMPS
I i ndefaan Y s all be used as public recoNs.
SIGNS ELECTRICAL.
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 nm exempt fromCoramnthe Coniratofs Licenu Law for the
TIiMP.MB'IER ON I'OLB(NST.
trod Professions Code: Any <iryorumnly,
requaata.loutan)(DLS,t,ainos
which its coca a permit m ams the alma improve. demolish, or repair any ntmalurc
which
its censed.alecuumtth the epphcamformcbpermiuo NeaeLao sWmmcnt
POWER DEVICES OW
that he is ncing w pursuant to the provisions of the Conuactors Licere Law (Chapter
that he
Division Needexemptio Professions Cade)
9(rommeis
SWIMMING POOL ELECTRIC
VALUATION
exempt tSection]OW)of
onto he is 1.5 by a therefrom and the basis fur the alleged exemption. to Any violation of
the
Section O(UI.S by any appliamfor a pcmiit subjects the applicant toacivil penalty of
OUThEfS- SWITCIIPS- PIXTURCS
not more than five hundred dollars (SSW).
❑ 1,asawnernfthepmp rty,ormyemployeeswithwagesasthcirsolecompearmion,
NEW R6SIDENTIg1.liLECIR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will Mt thework, mature suuaure is not imendedoroffered forsale(Sec. %DM. Business
and Professions Code: The Contractors License law does not apply to an owner of
property, whobuilds or improves themon.and whodaes such work himselfor through his
own employccs, provided that such improvementsarc not intendednroffered forsale. If,
OCC GROUP
RES. UNITS
T
however, the building or impnrvemem is hath within one year of improvefor purowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEF.
''ale')'
❑ 1.asownerofthe Mopeny,=cxclusivelycon=tingwithliccnxdcontmetorsto
FLOOD ZONE
APN
construct the project (Sec. 7000, Business and Professions Calc:) The Contractors
License Low docs not apply to an ownerofproperty whobuildsor improves tbercan. and
PERMIT ISSUANCE
who contracts for such projala whb.trado cto Of licensed pursuant,, the Commeon,
License Law.
A[AI:R -DRAIN & VI7NT- WATER (IA)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this o nasm
BACK FLOW PROTECT. DEVICE
OUTSIDE116
SANITARY Y N
RECEIPTp
Owner Date
DRAINS- FLOOR. ROOF, AREA, COND.
TIO
WORKMAN COMPENSATION DECLARAN
SCHOOLTAX Y N
❑ Iherthyal'Ermlhntl Lnvcacenifialcofec)nsenuoself-inxnm,oracerifateof
Workets'Compensodan lnsamoccoracertifedetrpy thereof(Sec. 3800. Lab CJ which
n ell employee's undef this permit.GAS
Policyis
RECEIPT M
FIXTURES-PER)'RAP
PARK IEE Y N
RECEIPT M
- LA. SYSTEM -1 INC Y OUTLETS
BUILDING DIVISION FEES
Company
GAS - FA. SYSTEM -OVER 4 (EA)
PLANCHECK Mil
❑ Certified copy is hereby fumisMd.
GRI:ASMNDUSTRI, WASTE INTERCEPTOR
GRADINGFEE
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This sectionnecd not becampleted iftbe pcmail is future hundred do11an($1007
mless.)
WATER HEATER WNENT/ELECTR
I cenifylhm in the redonranceof the work for whichthis pcmtit is issued, leball
not employ atry person in any manner so as to become .subject to the Workers
PAID
Campcnxation Lawsof Culifomia. Date
WATERSYSTEMIT'RIATING
It, It ReceiptX
Applicant
NOTICE TO APPLICANT:ILafar making this Certificate of Exemption. you should
NEW RESIDENTIAL PLMIL SQ, FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forth , ith comply with such provisions or this permit shall be deemed invoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herehy affirm that them is a ennsuuction lending agency for Ne perfomunce of
the work for which this perem, is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE res
QTY. MECHANICAL PERMIT FEE
PLUMBING FFai
Lcndds Name
Lender's Address
1 certify that I have read this application and state that the above information is
amenl, l agree m comply with all city and county ordinances and state laws relating m
PERMIT' ISSUANCE
MT:CIIANICAI.Igili
Wildinga nsurtw tor, and hereby authnrim representatives of this city weomr upon the
above-meminned property for inspection purpnvea.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO I(LOW CFM)'
(Wc) agree to save, indemnify and kap harmless the City of Cupertino against
liabilities,judgmems,cos and exile swhich mayin any way acemeogalad said City
AIR IIAN ULING UNIT (OVER lO,gq CPM)
quo of the mingnf :permit.
EXHAUST HOOD(W/DUCI)
PAID
Signature of plicant/Confullm Date
HEATING UNIT(TO J0LKS)BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dare Receipt If
I [EATING UNIT (OVER I W,IXNI BTU)
'TOTAL:
Will the applicant or future building occupant store or handle haamomis material
us defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
�'
PISkAN
Code, Section 25532(a)t15C
❑ Yes ❑ No
DATE
Will the applicant orfmumbuildingoccupart uuequipment ordevices whammit
air contaminants as defined by the Bay Area Air Quality Management
BOILER- COMP(3HF OR 100.000 BTU)
Not/
BOILER - COMP(OVER [00,001) BTU)
'hazardom
Didri Y'1
tl 2� ����
NEW RESIDENTIAL MT:CH. SQ. Ff.
El Yl, ❑ No
01)r
1 have read the hamNous materials requirements under Chapter 6.95 of the
Califomia Health & Safety Code, Sections 25505.25533 and 25536. 1 understand thin
0- l.Ur t�
if the building does not currently have a term, that it is my responsibility to notify the
capanl of the requirenmnd which must hemet prior to issannce of a Certificate of
Occupancy.
ISSUED BY:
Owner or authorimil agent Dam
TOTAL:
OFFICE