26265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO v¢mNc-erxcT97CA PERMITNo.
APPLICATION/PERMIT PLUMBING MEcnnrvlcnL 26265
BUILDING
DRESS- SIDN BUILDINOPRO,IECT IDEN'I IFICA'f10N "
BUIhDIN� S� - SANITARY NO. APPLICATION SUBMITTAL DATE
.UNIT# LOT ' �---1
OWNERS F:: _ PHONE CONTRA R'S NAME: LIC NO:
ef N/C �CO`NTROLN
RCHITECT/ENGINEER: LIC NO: ADDRESS - ❑
IM TAM:r PHONE: .BUILDING PERMIT INFO
9 jz ` QTY, ELECTRIC PERMIT FEE BId�.�, ELECT PLUMB' ryMMB[[���CCI�11ww�11
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
Metz I hereby affitm that l sm licensed underprovislonsofChapter9(vommeneingwith
FFcOC Section 9000)ol'Division 3 of the Business and Professions Code,and my license is in PANELS - 1
F Zrf; fulluseclud effect. ✓�
µE License Class Lic.N UP TO 200 AMPS (`\ I /✓,r/^� f"r'S,�)F�'1..IV'
m=� Date - Contractor 201-IBM AMPS S FT.FLOOR AREA $/SQ.FT.
zO-` � ARCM mm's DECLARA9'ION OVER 1000 AMPS Q'
CZ-0 I understand my plans shall b.used es public records.
�nSIGNS ELECTRICAL
Licensed Professional -
'�� C OWNER-BUILDER DECLARATION SPECIAL CR2CUIT/MISC.
°fit Oa on I hereby affirm that 1 am exempt from the Canovanas e:Any Lawcity o for the .
W 3 W h¢ following fires a(Semon 9031.5,Business and ere,de Professions Coda:Any pity orru county
ura TEMP.METER OR POLE INST.
�uJ�..l which reyuiresaPermit to construct,altar,improve,demolish,or repair any structure
co priormitsissuance,alsorequirestheapplicantforsuchpermittofileasignedstacement POWER DEVICES
W g that Its is licensed pursuant t.the provisl.as of the Contreetois License Lew(Chapter
Lp,o�L 9(commencing with Section 9000)of Division 3afiha Bminessand Professions Cade) SWIMMING POOL ELECTRIC VALUATION
i,M, or thnt he is eventual rculdnmaM the basis far the alleged exemption,Any violation of UTLEpS-SWITCHES-FIXTURES
t Z G Sermon 9031.5 by any applicant for a Permit subjects the applicant to a civil penalty of Lam/
I live hundred dollars($500).
C M m,asowncroftheproperty,nrmyemployees withwagcsasrheirs.lecompensation, NEW RESIDENTIALELECTR _SQ.FT. - STORIES TYPE CONSTRUCTION
ill the work,and the structure isnot intended.roffcmd forsan(Sea]044,11romess
and professior,Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his -
employees,pr.videtl thatsuch improvements are notimended proffered fnrsale.IL OCC.GROUP RES.UNITS
Loweveq the ave the
or Improvement is sold within one year or improve
the owner- T
builder will have Ne burden of proving that he did not build or improve for purpose of
sale.).
❑ Las ownerofthe progeny,amexcludvely contracting with licensed conuacmrs t. QTY. ,. PLUMBING PERMIT REE PLOOULONE APE
construct the project(Sec.9044,Business and Professions Cot The Contractor's
Licensel.awdoes not apply to an ownerofpropertywho builds orimprovaslheman,and PERMIT ISSUANCP. -
wb.c.ntm.t5 for such projects withacontmctnr(1)licensedpumuan[to the Contractor's AL'TEft-DRAIN&VENT-WATER(EA) '
License Law. FEE SUMMARY
❑ I um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner - Date DRAINS-FLOOR, F,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherchy affirm thmlhave aoertificate of eonummself-insure,oracenlflcam of eGR�SUINDUS7111,NWASHIN
R'fRRECEIPT#
Workers'Comlmiiationlnsumnceoraceniriedmpythereof(Sao.3S00,Lab CJwhlch PARK FEE Y N
,sell employee's under this permit. EM-IUTLETS - RECEIPT#
Policy# BUILDING DIVISION FEES
Company` EM- (E PLANCHECK FEE
❑ Cell copy is hereby furnished.
❑ Certified copy is filed with the city inspersion division. IN ;RCEP1'OR GRADING FEE
CERTIFICAI E OF EXEMPTION FROM WORKERS' GRP.ASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nit be completed ifihe permit fs for one hue dollars($100) SEWER-SANITARY-STORMEA. OFT. ENERGY FEE
.,less.)
I certify that inth�perfommvce of[ho wed PorwblcM1 Ibis noir isiesued,Ish
noan WATER ATERW y'/ELECTR
t employ person in any manner so as t.become s jam to the Workers PAID
z Compensation laws of California. Date TP. Data Receipt#
Applicant
�O NOTICP.TO APPLICANT:If,after making this Cenifcate ofG output on,you ould N RE. D ALP SQ:Pr. TOTAL:
p) become smbjecnathe Worker's Compensmion provisionts of the bus Code,y. ut
� ? forthwith comply with such Provisions.,this permitshall be dee eJLn P BUILDING FEF.
W (� CONSTRUCTION LENDING AGENCY rev - - SEISMIC FEE
z I hereby affirm that there is a construction lending agency for I perfmmance o
O the work for which this permit is issued(See301 Civ.CJ L: 01 ELECTRIC FEE
Lender's Name
F Under,Address QTY, MECHANICALPERMIT FEE PLUMBING PEE
U I certify that 1 have read this application and state[hat the tMve in ution is
r�" CkI correct.I agree to comply with all city and county ordinances andatalnlaws re PERMIT ISSUANCE / MECHANICAL PEE
U z4liabi
building construction,and hembymilamiu representatives ofthis city metric,upati[he / - CONSTRUCTION TAX
e-mentioned perry for in: ian purposes. ALTER OR ADD TO MECIL
(We)Oak, o,Inde end keep hormlass the City of Caperton against
iii v,ju cnts.l.1t, pcnaes whichmayivwy way accrueagn'nat geld Chy AIR HANDLINGUNIT(TO IQ000CPM)ol'thispe �IAIR HANDLING UNIT(OVER 10,000 CPM)
ma
in a re of Appl' a, Contractor Dae EXI IAU ST IIOOD(W/DUCT, _ PAID _
HAZARDOUS Ming occALntsomeDISCLOSURE
HEATING UNIT(TO 100,000 BTU) Data ReceiptIf
Will the the Cuntonfumrebmpal Code.Cantsmreo,handle hHealth and Safety HEATING UNIT(OVER 100,000 BTU) TOT L:
terial
as defineA io the 32(arlin.Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section Visa x)9 VENTILATION FAN(SINGLE RESIDi - i
-
11 Visa ❑No
Will tai,co lcunmrfumre building bco de Bae equipment ordevlcea wbleh rand
BOILER-COME(311P OR 100,000 B'I'U)' ISSUANCE DATE
hazaict?' air<mmnminants as defineA by tie Bay Area Air Quality Management BOILER-COMP(OVER 100,003 BTU) A. D
District?'
:s❑yes ❑NnNEWRESIDENTIAL MSCI I. SQ.FT. nn
1 have read the hazardous materials requirements under Chapter 6.95 of the q 11 X994
Culif,mia I lonith&Sofery Code,Sections 25505,25533 and 25534,I dndemtand that
If the building does not currently have a tenant,ilial it is my responsibility to notify the
o ectuc [of the requirements which must he met prior m issuance of a Certificate of Ur LUt'
Occupancy. tNIgV
Owner a rauthnrivedngent Date T ISSI]ED BY:
OFFIC '