27140ICI'L'Y OF CUPE
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BUILDING DIVISION NO APPLICATION/PERMIT PLUMBING - MECHANICAL ee�rrr
I BUILDING PROJECT THENI'IF'ICA9'ION 27140
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QTY. ELECTRIC PERMIT FEE
SOILS FEE
BLDG ELECT PLUME
ENERGY IEE
Ohissecionness! becamplcted if Ne permit is fnanehundeddollars(SIW)
orlasJ
PERMIT ISSUANCE
I cenif dint in the performance cftbe work for which this pemait is issued, l shall
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not employ any penon in any manner so as to become subject to the Workers'
LICENSED CONTRACTOR'S DECLARATION
Thereby Ona uACTOR'iaDECL RATI9(commencingwith
APPLIANCES -RESIDENTIAL
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Section 700(n of Division 3ofdan Business and Profession, Code, and my he.. is in
fall force and effect,
License Class Lic.k
Dam Contracmr
ARCHITECT'S DECLARATION
l undersmnd my plans shall be used as public remands,
PANELS
UPT02MAMPS
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201 -IOW AMPS
OVER LOW AMPS
SQ. FT. FLOOR AREA
SIGNS ELECTRICAL
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Licen¢d Professional
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OWNER -BUILDER DECLARATION
1 hereby affirm that I ora exempt from Nw e Contractors License lafor the
following reason. (Section 703 1 5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any sarcomas
prior equina pp pe gne
to its issuance, also the applicant for such Smit Eleasi dmmment
SPECIAL CIRCUHUMISC.
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THMP. METER OR POLE INST.
POWER DEVICES
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that he is licensed pursuanua the provisions of the Contractors Lucerne Law (Chapter
9(commencing with Section 7")of Division Sof the Business and Professions Code)
QTY. MECIIANICALP17RMIT FEE
SWIMMING POOL ELECTRIC
VALUATION
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onhat he exempttherefrom and the basis for the alleged exemption. Any violation of
Section 0031.5 by any applicant for a permit subjects the applicant a civil penalty of
not mart than Eve hundred do[]. ($500).
❑ I,mownemftheproperty.ormyemployeeswiN wagnaa theirsolecompensetinn,
will Ja the work.anJ the structure is not intendMornffemdfort sale (Sec. 7IH4, Business
ALTFER OR ADD TO MECH.
OUTLETS - SWITGHFS- U itac
NEW RESIDENTIALE .
STORIES
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and Profession Cale: The Contractors License Law does and apply to an owner of
A IR I IANDIANG UNIT (TO I(fight Cl
Inenme enflhe gra tin of thi.
property whobulldsorimprevesthereon, andwhodoessuchwod himselforNrough his
own employees, p that such tmprovememtt atenot intended offered fheowp
OCC. GROUP
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TOTAL:
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builder. .Neavet a ndearofemein issoldheili within buildne ormprove for or
builder will have the burden of pmvimg that he dIJ not build or improve far purpose of
PAID
QTY. PI! RING PERMIT FEE
HEA'L'ING UNIT(TO IW,WOBTU)
❑ [,as owner offfic progeny, war exclusively contracting with licensed contractors to
FLOOD ZONE
IIAP.ARDOUS MATERIA.S DISCLOSURE
consumer the project (Sec. 70,44, Business and Professiom Code:) The Contractors
License Law doesnot apply torn ownerofpropeny who builds or improves th num,sad
HEATING UNIT (OVER I W,IXp BTU)
L:
PERMIT ISSUANCE
Cade, Senior 25533(n)7
❑ Yes ❑ No
who contracts fonuch projects with a contractions) licensed pursuant to the Contractor's ve Law.
License
ALT[iR -DRAIN&VENT - WATER (FA)
FEE SUMMARY
ISSUANCE ATE
OCT
Ell am exempt under Sec. , B & P C for this mason
BACK FLAW PROTECT. DEVICE
BOILER. COMP (OVER IW,000 BTU)
SANITARY Y
Owner Duce
WOR MAN COMPENSATION DECLARATION
DRAINS - FLODR, ROOF, GOND.
RECHIPT#_
SCHOOL TAX Y
NEW RESIDENTIAL MECH, SQ. FT.
❑ Iherebyaffirmthurlhaveacerifemeofconenttoul6insum,oracenificateo(
Weakeri Compensation Insurance or a cenifiecl copy thereof (Sec. 3800, Lab C.) which
RECEIPTX_
FlXTURFS - PER TRAP
PARK FEE Y
mvemallemploya's thderthis permit.
Policy M
GAS - EA. SYSTEM -1 INC. 4 OUTLINE �•
RECEIP #
BUILDING DIVISION F
Company
❑ Cerufim copy is hereby fumhhed.
GAS - EA. SYSTEM -OVER 4(III
PLANCHECK FEE
1 1 GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
or authorized agent Dam
❑
CHR I'117TCAI1' Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM FA. 200FT.
ENERGY IEE
Ohissecionness! becamplcted if Ne permit is fnanehundeddollars(SIW)
orlasJ
WATER HEATER WNENT/ELECTR
I cenif dint in the performance cftbe work for which this pemait is issued, l shall
not employ any penon in any manner so as to become subject to the Workers'
PAID
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Cmuramiumsawauf Califomia. Date
Applicant
NOTICE TO APPLICANT:If,ofter makingchia Cerificmeof Esenaptiar. you shoudd
WATER SYSTENVOEATING
NBW RESIDENTIAL PLMB. SQ. FT.
Date Receipts
TOTAL:
Vbecnmc.rubjeatntit.
Wmkcr'a Compensetimprovisions of the Labor Code, you muse
5
forthwith comply with such provisions or this permit shed l M deemed revoked.
BUILDING FEE
SEISMIC FEE
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CONSTRUCTION LENDING AGENCY
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I hereby affirm that here is a construction lendtngagency for the performance of
the work for which this permit is Issued (Sae. 3097, Civ. CJ
Lender's Name
ELECTRIC PEE
Lenders Address
QTY. MECIIANICALP17RMIT FEE
PLUMBING IEE
1 certify them I have Had this application and state thin the mhove infmmatum is
correct. Ingrcemcomply with all city and county nrdinencex and stale lows relwingmT
building construction, and hereby authorize representatives ofthis city mentermen the
above-mentioned property for inspection purposes.
PERMITISSUANCE
MECHANICAL FEE s�
ALTFER OR ADD TO MECH.
CONSTRUCfIONTAX
(We) mgrte to save, indemnify and kcep harmless the City of Cupertino.,.fast
liabilities, judgmems, costs and expenses which um,m ny wnyaccrue gainstumd City
A IR I IANDIANG UNIT (TO I(fight Cl
Inenme enflhe gra tin of thi.
s
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AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCI)
PAID
S' sum of Applicam/Contmcuse' Dam
HEA'L'ING UNIT(TO IW,WOBTU)
Dam Reccipt0
IIAP.ARDOUS MATERIA.S DISCLOSURE
Will the applicant or future building occupant arm or handle hazardous material
as defined by the Cupertino Municipal Code, Clmpter 9.12, and the Health and Safety
HEATING UNIT (OVER I W,IXp BTU)
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Cade, Senior 25533(n)7
❑ Yes ❑ No
es-
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al `1 I y
VHN'1'l1ATION 17AN(SINGLE RESID)
BOILER- COMP(3HPOR IW,a(IB BTU)
ISSUANCE ATE
OCT
AdKp
Will Neo plicanrorfmurebuilding«cu pencuuequipmentordevice,whtchemit
BOILER. COMP (OVER IW,000 BTU)
haurdnus air contaminants ax definW by the Bay Area Air Quality Management
District?
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❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 undmiumul that
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NEW RESIDENTIAL MECH, SQ. FT.
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7Owner
if the building does not arurently have it tenant, ilia, it is my responsibility to notify the
occupant of the requirements which must be ran prior to issuance of a Certificate of
Occupancy.
ISSUCD BY:
or authorized agent Dam
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