27323APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINU - '
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
- PERMITNO.
27323
BUILDING ADDRESS:
UNIT# LOT#
SANITARY NO.
�APPLICATIONSUBMITTALDATIE��
�- / %
.FRS`@MG: /'T( PHONE:
C RAC-VOR'S E: LIC NO:
N/C
ONTROL#
DIT/- � s4rIV,1.W�
ARCHITECT/T:NGINEEIC LIC NO:
A yDdRE y♦� J%
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FE8
BUILDING PERMIT INFO
BLDG ELECT PLUMIL MUCH
PERMIT ISSUANCE
❑ 0
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm deal am licensed under provl sl on s of Chapter 9 (commencing with
APPLIANCES -RESIDENTIAL
LOB DESCRI ON
allSeeftmvind of Division3.fine Business end Professions Code, and my license is in
end effect.
pAN.E(,g
Liemirce
I license Class - Lic.#
UP TO 2W AMPS
{ Date Connote
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall homed as public records.
OVER 1000 AMPS
SQ. FI'. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Prefesumed
SPECIAL CIRCUIT/MISC.
{ OWNER -BUILDER DECLARATION
1 hereby affirm that 1 nm exempt from me Common's License Law for the
TEMP. METER OR POLE WST,
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which ommote a permit t. construct, alter, improve, demolish, or repair any structure
prior to its issuance, also romirestheapplicant for such Permit to fileasigned statement
POWER DEVICES
that he is licensed pumuantro the provisions ofthe Contractor's License Law (Chapter
9(commencing with Section 7000)of Division 3 mthe Business and Pondered... Code)
SWIMMWGPOOLELECTRIC
VALUATION
or he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OUTLETS - SWITCHES - FIXTURES
not more than five hundred doll... ($500).
111,asowneroftheprnperty,ormyemployeeswithwagesastheirsolecompensation,
NEW RESIDENTIAL ELECTR 5 . PT.
Q
STORIES
TYPECONSTRUCTION
will do the work, andthestrucwre is not intended muttered forsale(Sec, WAF, Business
and Professions Core: T e C.mractors License Law does not apply no an owner of
property who builds or improves t1ammon.and who does such workhimselforthroughhis
own employees, provided that suchimprovemems arenmineaded oroffered formic. If,
OCG GROUP
RFS. UNITS
however, the building ar improvement is cold within one yearofemapletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
QTY. PLUMBINGPERMIT FEE
sale).
❑ I, asowner o0he property, am exclusivelycontracting with licensed contractors to
FLOOD ZONE
APN
construct the project (Sec. 7tW4, Business and Profession Code:) The Contractor's
License Law docs not apply m an ownerofpmperty who builds or improves therenn,and
TPERMIT ISSUANCE
who canracts forseth projects with amonuments) licensed puts .... (.the Cmumseas
License Law.
ALTER I' -WATER (EA) -
FEF. SUMMARY
❑ I am exempt under Sec , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEE
Owner Date
DRAINS- FLOOR, ROOF, AREA. CONED.
SANITARY Y_N
RECEIPT#
WORKMAN COMPENSATION afros DECfARATION
T
❑ Thereby nffrm thmlhave ecenificate of consem to self -insure, ore certificate of
Workers'C.mpcnsation Insurance or streamed copy thereof (Sec.3X00, Lab C.) which
SCHOOL TAX Y N
RECEIPTS
IX'fURES-PER TRAP
PARK FEE YN
em 111 employee's under permit.
Policy p
GAS - EA. SYSTEM -1 INC. 4OTTLETS
RECEIP #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cerific l copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GREASF✓INDUSTRLWASTI?INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not becomplemd ifinepertnit is for one hundred dollars ($100)
or less.)
WA IELELTR
I certify that in the perfmnnce of me work for which this permit is issued, l shall
not employ any person in any mammy so as to become subject on the Workers'
Compensation Laws of Califomia. Dam
Applicant
WATERSYSTEM/1R G
PAID
Dam Receipt#
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
mxmlESIDzIAL PLMIL SQ. FT.
become subject to the Worker's Compensation provision of the Lobar Coda, you must
forthwith comply with such Provisions or this Permit shall be deemed revoked.
B LUNG FEE
CONSTRUCTION LENDING AGENCY
EISMIC FEE
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
T L
LEC RIC FEE
Lender's Address
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that 1 have read this application and state that the above information is
rest. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MF.CHANICA4F '
building construction, and hereby authorize representativesof this city in entermin, the
above-mentioned property for inspection p.,.a..
-
ALTER OR ADD TO MECH.
CONSTRUCTIO
(We) agree t. on, indemnify p h less the City of Cupertino against
liabilifies,judgmentr, costs ands w
whichmany weyeccme agninstswd City
AIR HANDLING UNIT (TO IU,IMI) CFM)
s it fi peme,
�
AIR HANDLING UNIT (OVER HINJOCNE
ore of Applicant/C von ! Dom
EXHAUST HOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEA TING UNIT (TO IW,)00 BTU)
Will the applicant or future building occupant store or handle hazardous material
as defied by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
TOTA4:
HEATING UNIT (OVER 100,1100 BTU)
Code, Section 25532(m?
❑ Yea 11 No
VENTILATION FAN (SINGLC R651D)
by the ay Area Aiequipmeres uality eswidth emh
Will air co� applicant on, as defindinged
air contaminants as defined by the Bay Area Air Qualify Management
Di.E e,
BOILER- COMP(3HP OR 100,000 BTU)
r+p
ISSUA ,"A'[#JA
NOVNons
/ T
BOILER -COMP (OVER 100,000 BTU)
❑ Yee ❑ No
1 have read the hazardous ..,costs reyuiremcnts under Chapter 6.95 of the
Califomia Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that
if the building utas not currently have a home, that it is my nomomihilify to notify the
aY 22198 /I
Y'
Uh ,L,, C:KT ffl/f /
NEW RESIDENTIAL MECH. SQ. FT.
accepted of the rommments which mus, be met prior t. issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or authorized agent Date
TOTAL:
Ll"lct