27046 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- LE A. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI, 27046 O /I
; ,j,j;, s.i.,rB_UILIIINO PROJECT'IDENT'IF'ICATION G 4}
BDILDING'GA.11)1DRPSS�l: �1 ! SANI'PARY NO. APPLIGTION SUHMITTAL DATE
D { �`� IILU•W/,// ON19'# LOT#
OWNERS P a PI��IE CONTRA A E:
7, I .:1`'I-�3 N/C CONTROL#
42
RCHI'I'E ENGINEER: LIC NO: ADD ❑
'o Cl': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1 IW PERMIT ISSUANCE BLDG ELECT PLUMB ECt
LI SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
y2 Iherchyaffimnl atlam licensed underpmvisionsof Chapter9(eommencingwith JOB DESCRIPTION
00 Section]WO)ufHk eion3ofthe Businessans �x�odp,end my license is in PANELS
y�Ffu
ll furceanJ
Licert—u ClssI�s-���IY4`-s��(/y—~-�--Lia# 1 (/FW/ UP T0200AMPS
F v60i y Dale a'- 1"xa ARCHITECTS D 201-1000 AMPS SO.FT.FLOOR AREA S/SQ.FT.
20yi� OVER 1000 AMPS
02,..0 1 undenund.,,]am Shull be used as public records.
�y
Licensed Professianul SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUII'/A118C.
ejOyF I hereby eRrm That 1 am exempt from the Contrectals License law for the
3)3 Wya following nonan.(Salim]031.5.Business and Frofessioru Cade:Any city nrcounty TRW,METER OR POLE INST.
�.I which uquims.peanut he core0uc0 her,improve,demolish,or repair any structure
F Y� Pricer to!is issuunce,ulso mumu.theapplicant I..ch pamiuo file.signedmamunt FEWER DEVICES
0 that he is licensed lam a rat to the pr.A.i.m of the Cmanda r'x License Law(Chapter
p0 9(commcacing with Section 7000)of Division 3 ofthe Business and Poofessime Code) SWIMMING POOL ELECTRIC VALUATION
_y or that he I.exempnherefrom and the basis fortbealleged exemption.Any,m.thm of
��i• Section 7031,5 by any applicantfar.Permit subjects Nespplicant toe civil Penalty of OUTLETS-SWITCHES-FIXTURES
G not more than five hundred dollen(5500). NEW RESIDENTIAL F.LECIR _SQ
K ❑ Lazowneroftheproperry,ormyanplayreswith wagnutheirsolecompemadon, TORIES TYPECONSTRUC ION
y _ willdothe wmix,undthemvnuu is sol inunded orof(crcd Tarsale(Sa.]044,Business
and Profession Code:The Cr idwooes License Law Jas not apply to an owner of
property who huilds or improves theunn.und whodas such work himselforthrough his CC. OUP RES.UNITS
ownemployees,provided nonsuch improvementsnrt not imm�tlW oroffered for�ale.If,
however,the buildingor improvement is sold within one yemofecmplefion,the owner. TOTAL:
builder will have the burden of pmving Nal he did not build or improve for purpose of
We.).
❑ I,maemer uffhe propeny,amexclusivelycontmeting with licensed contractors he QTY. PLUMB[NG PqdMIT FLO DZO APN
construct the project(Ser.7044,Business and Professions Cale)The Contactors
License Law Jnes natapply Loon ownerofpropeny who bulldsorimprovesthereon,and PERMIT ISSUANCE
who contracts for such projects with acornacmr(s)licensed punu.nt to the Contmemes ALTER-DRAIN&V -WATER PA
License Law. WATER(EA) FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for Nis urian BACK FLOW PROTE '.DEVICE
V FEES
SANITARY YN
Owner Dam DRAINS-FLOOR,R F,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOO AX YN
❑ I hereby uffrm that l have a certificate ofcnnacnt m.self-imme,ara certificate of - RECEIPT#
orked,Core r cenift FIXTURES-PER TRAP
,$ �y�J�7y theuof(Sec.383),Lab C.)which PAR HE YN
covers ellemplsi k#Ytig //AU GAS-FA.SYSTEM-I INC.40 S RF.CP.IPI'p
Policy V L!7-' BUILDING DIVISION FEES
COntp°ny A Is! GAS-EA.SYSTEM-OVERO(EA) IANCfiF.CK FEE
❑ c sea Dopy is neany res .e .
❑ mifeJ copy is fled wide the city inspcetion drnsmm GREASEONDUSTRL WASTEINTF.RCP.PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This.1m.nadmobceompleted ifthepnmit b leronehunduddollau(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I codify that in the performance of the work for which this permit is issued.)she] WATER HEATER WIVENTIELECTR
not employ any person in any Amour an a+in hecome subject to the Worked PAID
Camperevamalawsof C.lifumia. Date WATER SYSTENUTRFATING Dam Receipt#
O O Applicant _
'Z NOTICE TO APPLICANT:ILaflea..king this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r fn bacamddjeel lm the Workerx Compensation provisions of the labor Coda,,im must
forthwith comply with such Provisions or this pentad shall he damn d invoked. BUILDING FEE
2 CONSTRUCTION LENDING AGENCY SEISMICFEE
I herehy.form that there iso c...handle.horai n8.gency for the poffinnome,of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.7
Ix, oLender's Name -
O Lender,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify flet 1 have is application and sum that the above information is
condct.Iagrata compl w all city and county ordinances and state laws relining m PERMIT ISSUANCE MECHANICAL FEE
to building construction,a her yaufhoriumpms ntativesofthiscirymenterupon the CONSTRUC IONTAX
U 4 above-anni innM props y far s coon purposes. ALTER OR ADD TO MECH.
F7 (We)agree to sav,in d keep harmless f Clry of Cope hiring
no ug net
Iinbilities,juJgmems,c uan a ns whichmeyi yweyucmea "said iry AI ANDLING UNIT(TO 1a,H00 CFM)
in consequence of the g antis ii it. 1
IY, AIR HANDLING UNIT(OVER 10,03)CFM)
Signature Af Apdowa nor me EXHAUST HOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 13),000 BTU) Date Rceeipt#
Will the applicant or future building oceupant Rom a handle le urdom anderial
as defined by the Cuporina Municipal Cade,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade.Section 25572(a)?
❑Yes ❑Na VENTILATION FAN(SINGLE RFSID)
Will theappllcnntorfmurehuilJingacupant uuequipmemmdeviccs whichemil
BOILER-COW UHP OR 13),03)BTU) IISSI*rICLDATE
durdous air emitaminan s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
""' NOV 101994
❑Y. ❑Na NEW RESIDENTIAL MECH. SQ.FT.
1 have rtW the worm oro materials requirements under Chapter 6.95 of the CITY ser wra=tt l uvU
California Health&Safety Code,Sections 25505,25533 and 25534, 1 understand that
if the building does not currentlyich utenant,let itis my responsibility Ionotify the
Occupancy.cupant of the rcquirmnenu which must ba met prior m ixsuance of o Cenifeate of
Ownermamhoriud agent Date TOTAL: SSUED BY:
OFFICE