27623APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IB:6IKG-FEEcrn7r•AI. PERMITNO.
APPLICATION/PERMIT PLUMBING - MECHAN'ICAI. �i
BUILDING DIVISION BUILDING PRO I RCT 1DFN`E14lCAT1ON J
Oy` i ,' 1 v!ITN'ITM LOTS
INI(LIIIICI:I/LIVISIryLIX; LIr, NO:
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,ONT'ACT: PHONE:
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QTYt ' r )' '(, ELECTRIC PERMIT FTE
r BUILDING PERMIT' INFO
BLDG ELECT PLUMB MECH
1 PERMIT ISSUANCE SIX
LICENSED CONTRACTORS DECLARATION
(commencing is in
Ihateby of Diihatl am ofiliculinssand rofesio Ch Code,
Section TOlXp of Division Sof the Business and Professions Codc, and my license is in
full fince and Cla,, ffttn.
l.icensu Clues Liup
Data Contractor
APPLIANCES -RESIDENTIAL
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1+100
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Ipy DESCRIPTION
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PTCO -
pprypyS
UP T0200 AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
1 undersl:mJ my plans shall be aced as puM1liC recoNa.
OV ER 1000 AMPS
SQ.IT. FLOOR AREA
E/SQ.IT.
SIGNS ELECTRICAL
Licensed professional
�YFJ
C)m6
Px'Oe.
F4por
OWNIiR-BUILDER DECLARATION
1 hereby affirm that 1 con exempt from [be Convectors License law for the
following remain. (Section 7031.5. Business and Professions Code: Any city or county
which squires u permit m amsm,a, alter, improve, demolish, m repair any structure
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
$s�}2
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dWo�
ujl2,
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primmusissuance.miat resimon theapplicant for such pormiuo Fla. slgnM statement
that he is licensed pumuan
no the provisions oflhe Contractor's License Law (Chapter
9(cnmmenoing with Scnion 700()of Division 3ufthe Brainessand Professions Code)
nr that he is exempt therefrom and the basis hotline alleged exemption. Any violation of
Section 7033.5 by any applicant for a permit subjects the applicant a civil penalty of
not more than rive hundred dollars ($500).
❑ I,asowncrofihepropeny.ormyemployeeswithwa8esazthmrsolecompenudon.
will do the work,andthe structure isomintended oroffened for We(Sm 704L Business
POWER DEVICES
SWIMMING POOL ELECTRIC .
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIALELECTR _SQ. FE
STORIES
I'YPF. CONSTRUCTION
and Professions Code: TI e Contractors License Law docs not apply to an owner of
progeny who builds or improves thereon, and who does suc h work h i mal f or Nmugh his
ownemploytts,proviJ<J thmsucM1improvememsere notimendedoroffcrcdforsale. IL
OCC. GROUP
RES. UNITS
T
however, the building or improvement is sold within one yew of completion, the owner-
builder will have the buNen of proving @at he did not build m improve fur purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑Lasownereflhepropeny.amexclusively contracting with licensed contactors to
M-OODZONE
APN
construct the projca (Sec. 70H4, Business and Professions Code:) The Contractor's
Liccnulawd«snot applymun owncrofpropcny whohuildsm improvesthamn,end
PERMIT ISSUANCE
who commma for such projects with acontruun(a) licensed pmirairtmilm Convector's
License Law.
AhfP.R- DRAIN&VPNT - WATER (PA)
FEE SUMMARY
❑ I am exempt under Sec. . B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUT IDE FM
SANITARY Y —N -
Owner Dae
DRAINS - FLOOR,ROOF, AREA, COND.
RECF.IPI' p
WORKMAN COMPENSATION DECfARAT10N
SCHOOL TAX Y N
❑ ers Coyafbrmthatlhuvem Cenilicateesimpythereclf-inu38 o. Lab C.)whicf
coveniCmmpanutionlnsurun¢rmit. fiW copy thereof (Sa.3800, Lab C.) which
raven ell cmpluyce'a under permit.
Policy M
RIiCF.IPI'M
FIXI'URCS-PE
PARK FCC Y N
REp
GAS- EA. SYSTEM- I INC.40 .E-fS
BUILDING DIVISION FEES
Company
❑ Candied copy is hereby furnished.
GA -EA. SYSTEM-OVCR 4(Ii)
PLANCHECK FEE
SIVINDUSTRLWASTEINTER F,PTOR
GRADING ITE
❑ CeniticJ copy is riled with the city inspection divi ton.
CERTIFICATCOFEXCMPTIONFRO WORKEtin,�
GREASC P
SOILS FEE
COMPENSATION INSURA E
8 ITARY-S'IbRM EA.2 Ill
ENERGY 1LE
(Thissationnewinot ecomplet iflhepermitisfo otchuns(EIW)
or less.)
WATER HF:ATF,R W/V R
I minify that in the performance oflhe work for which th pe.d.lsholl
not employ my person in my manner u m to become s bjecWorkers'
PAID
WA ERS RFA NG
z
Z
Comparratooi Lawsof California. Date
Applicant It
NOTICE TO APPLICANT: If, after making this Certificate of Ell ption,you should
Dae Receipt as
-WRBIDENTIALPLAIH. SQ. PT.
TOTAL:
(ry
�;
becmmesubjemmthe Workers Compensation previsions of the is Code, you mu
forthwith comply with such provismarior this permit Shull be deem
BUILDING FEE
SEISMIC PEE
WQ
Uz
O
L's ..
F
�%
f^
(� z
CO NST RUCDONLENDING AGENCY
1 harcry arum that there is a cnnatrSm.3 lending agency home peRurmmee of
theLe work for which this permit is issued (Ser. J09T, Civ. C.)
Name
TOTAL:
ELECTRIC I7EE
QTY.. MECHANICAL PERMIT PEE
PLUMBING FEE
Umder's
Lcndera address
1 certify that 1 have read this application and suite that the above infomwtim is
Corton. l agree to Comply with all city and county ordinances and rate laws relating to
building construction, and hereby audtorlee representatives ofmis city manner upon the
ioned progeny for inspcctinn pmgnes.
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION
r
gree no save, i damnify and kap hwmleas the City of Cupcnino against
liabiil hitch may; any way #'aj
ng
A IR HANDLING UNIT (10
A�.cnoaof the of�nscs
I
AIR HANDLING UNIT (OVER IQfpO CFM)
EXHAUST HOOD(W/DUC)
PAID
licunl/C ilncten DataU1,
I IEATINGUNIT(TO 100,000BN)
ZARDOUS MATERIALS DISCLOSURE
Data Recern a
II- TING UNIT (OVER 100.000 BTU)
TOTAL:
Will the applicant or future building occupant store m hadl< baranders material
as lefined by the Cupcnino Municipal Coda. Chapter 9.12, ani the Health cod Sme,
VENTILATION FAN (SINGLE RISID)
Code, Section 25532(a)R
ElYes ❑ No
ISSUANCE DATE
Will lhu IicunmrfuturebuilJin moue mrdevices whichanit
qua
pp grby
HOILF.R- COMP (JHPOR IW,(NN)BTU)
flOILFR. COMP (OVER 100.000 PTU) .
the Air
M1vuirr? air contamirnenu as defined by the Bay Area Air Quality Management
Diadny
N13W RESIDEN'HAL MECH. SQ. FE
❑ Yes ❑ No
PA
1 have mad the havuJous materials requirements under Chapter 0.95 of the
I Q
Ciddrmis Health&Safety Code. Sections25505,25533 and 25534. 1 understand that
if the building does no currently have a mount, than it is my responsibility to notify the
AN ! as
occupum of the requirements which most ha met prior to issuance of a Certificate of
ai IV+
Cecupancy.
,78
ISSUED BY: LI
Owner or authorised agent Data
TOTAL: