27571 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDNG-ELEC I RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L 1
BUILDING PROJECT IDEN'I'II+ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
LOT It ["1Z`
OW E S AME: Ow!Vr �� pppyli. CONTRACTORS NAME: LIC NO: C"
'NlrilV'1 SEC /}�CONTROLN
1RCHITECLUNGINEER: LIC NO: ADDRESS: ❑ 7 /yO
-CONTACT: PHONE: BUILDING PERMIT INFO
r QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �1 El El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL204z L�
P400 Thereby affirm that amlicensed unss nd Professions
Codle,add
(commencing with ljBB DE 1
P400 00E Section 9000)of Division 3 of the Business and Professions Cade,and my license is in ppNBLg `4 W / '
Fa�U full force and attar t
Fzw License Class LIC.# UP TO 200 AMPS
rn]y Date Convector 201-11100 AMPS
ZOr1°ir z�. ARCHITECTS DECLARATION OVER 1000 AMPS
MSQ.FT.FLOOR AREA $/SQ.FT.
O z.,M 1 understand my plans shall IN used as public records.
dW SIGNS ELECTRICAL
leeched professional
OWNER-BUILDER DECLARATION Cmameme SPECIAL CIRCUIT/MISC.
tr13 4 y 1 hereby affirm that I em exempt from the Contractors License Lew for the
U fullcwhal reason.(Section 7031.5,Business and Prefessions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any so-ucture
yah prior to its issuance,also requires the applicant forsuch permino file asigned statement POWER DEVICES
O p that he is licensed poolaro t to the provisions of the Conmacmrs License Law(Chapter
n9(commencing with Section 7000)ofOivision 3 of the Business and professions Cade) SWIMMING POOL ELECTRIC VALUATIONya or that he is exempnherefrom and the basis for the alleged exemption.Any violation of OIITLEfS-
G
Se" 70315 by any epplicam fore permit ambjects the applicant macivil penalty of SWITCHES-FIXTURE
O nut mom than five hundred dollare($5gp. NEW RPSIDENTIAL ELECTR
P�' m ❑ I,asowneroFlhepropeny,ormyemplpyecswiN wegesastheirsolecompensefon, FT. STORIES TYPE CONSTRUCTION
a will do the work,and the structure is not intended or offered for sale(Sec.7104,Business
and Professions Code:The Conuucmr's License Law does not apply to roan owner of
property who buiIdsor improves thereon,and who doessuch work hirmelfinthroughhis
employus,pmvidetl that such improvementserc not intended proffered Tarsale.If, OCC.GROUP EA
NITS
however,the building orimprovement is sold within one yearmcompletem.the owner- TOTAL:
builder will have the burden ofproving that he did not build or improve fur purpose of
sale.). TY. PLUMBINGPERMI'P N
❑ I,as owner Project
(See 70Fam Business
and Mesio with de:) his m dureb re Q FEE L� FLOOD ZONE
construct the project(Sec.91004,Business and ywhol lona Coda:)The Corrector's
License Law does rnot appjects with acontproperywhosed puorimproves thereon, PERMIT ISSUANCE
who commas for such projects with awntractor(s)licensed pumuanno the Compactors
License Law. ALTER-DRAIN&VLNT-WATER(EA) PP.E SUMMARY
❑ I am exempt under Su. ,B&P C for this reason BACK FLOW PROTECT,DEVICE SIDE FEE
Owner SANITARY Y N
Date DRAINS-FLOOR,ROOF,AREA,COND. RF.CELPI'#
leiWORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby aafimllbatlhave acerifcate,f msent b..teasel((ee.38 0,Lab C.)whichfiesucof FIXTURES-PER THAT, RECEIPT#
Works ll Player's de,thus mrecenified copy thereof(Sec.3g00.Lab CJ which PARKFE.E Y N
core-all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 EA) PLANCHF.CK FEE
❑ CeniFied copy is hereby famished. (
❑ Cmified copy is Ned with the city inspection division' GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE
INSURANCE
(This section need nosh completed ifthe Permit is forum hundraldollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
,ales'.)
I certify that in'he perfarmanceof the work for which this pemitis issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Z mpea Applicant tion Laws of Celifomia. Dam WATER SYSTEM/TREATING Date Receipt It
OC NOTICE TO APPLICANT:If,after making this Certificate of Exemption,y..should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
(q become subject m the Wmkers Compensation provisions of the Labor Code,you must
a ; forthwith comply with such provisions or this permit shallh deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
'U Z 1 hereby affirm that there is a connection lending agency for the perfomtaace of
U O the work for which this Permit is issued(Sec.31199,Civ,C.) TOTAL: ELECTRIC FEE
Lender's Name
w0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
1 certify that I have read Nis application and some that rine above information is MECHANICAL.FEE 0. correct IagreetocomPlrwirhallciryandepantymAinnaxemodsrarelawsrelaragm PERMIT ISSUANCE
building connection,and hereby authorize representatives ofthis city to enter upon the
U above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless the City of Capetian.against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IR"CFM)
Signature of ApplicanVContmmor Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupy d store or handle hazardous material
I--
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)Y
11 Yea 1:1 No VENTILATION FAN(SINGLE RPSID)
Will the emieamorfuwre refined
by the use Are.Air Quality Manageoldithement BOILER-COMP(3HP OR 100,00)BTU) ISSUANCE DATE
hazardous air coraminants n defined by the Bay Area Air Quality Manugemem
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health A,Safety Code,Sections 25505,25533 and 25534.1 understand that
Hthe building does concurrently have a tenant,that it is my responsibility to notify the
occupant oC the requirements which must h mu prior b issuamee of a Cepificate of
oepapanay.
Owner or authonzed agem pate TOTAL: ISSUED BY:
OFFICE
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