27783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIII'DINf'-ECELTRICA- PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 27783
BUILDING PROJECT IDEN'1'IPICATiON -
BUILDINGADDRFSS: SANITARY NO. APPLICATIONNSUMMITPAL DATL'
LW LOT» 3
OWNS S ME: PHONE: Cf0 SNAME: LIC NO:
63S
NIC CONIROL»
ARCIII f/ENG ,ER: LIC NO: 4MDRESS ��6 I717r I]
COM'ACf: PHONE: BUILDING PERMIT INFO
T�� � QTY. ELE 'RIC PERMIT FEE
QLII), ELECT PLUMB pH.
PERMIT ISSUANCE / L�.�`' .Pr
LICENSED CONTRACTOR'S DECLARATION APPIlANCES-RFSIOENTIAL 10B DESCRIPTION
cwz I herehyuffirm that l am licensed underprovisiunsofchapter9(commcncing with
F�OO Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS /'��
y qU fu11I .Jaffe.. UP T0200 AMPS �/ 1• a
F.2 u
License ass Lic,a S
rn6 y Da mc
Conttm 201-IOW AMPS
z4
: ARCHITECTS DECLARATION OVER Il1W AMPS
C ' SQ.PI'.FLQOR AREA S/SQ,FT.
O Z r'3 1 undersand my plans shell be used ns public records.
�¢an Licensed Professional SIGNS ELECTRICAL
x6yyG OWNER-BUILDER RATION SPECIAL CIRCUIT/MISC.
x0yF 1 hereby effirtn that I am ere m the Conuactore iartse Law for Ne
W
$LLO y followin mason. . , usiness and professions Cod:Any city or county TEMP.METER OR POLE INST.
IS y whit rtyuircs a permit to constma.ulteq improve,demolish,o pair any swcture
prior rigs issuance,also requires the applicant for such pcomitto f a signed statement POWER DEVICES
6)" 'hath is licensed pursuant to the Provisions ofthe Contractors Li case Law(Chapter
as 9(com en' with Section TXlp of Division 3 ofthe Business an Professions Code SWIMMING POOL ELECTRIC
r2 crag wi ) ) VALUATION
y�_y onhath is exempt herefrom and the basis for the alleged exempti .Anyvioladonof
GSection 31.5 by any applicant for a permit subjects the applicant acivilpenalryof ETS-SWITCHES-FIXTURES I O
nm more ten five hundred dollars($500).
o ❑ Las, nerofthepmPerty,or ycmpl nstheir oIccmr,.xatmn, NEW RESIDENTIAL BLECfR _SQ.Pf. S'1'OKIFS TYPE CONSTRUCTION
p, .a willdothe ork,and'he. clami of dcewt fcrcdforaskC .TW.Husiness
and Fades, on Cade: r'. nu Law does not ap ly to an owner of sa
property as 'b ' p e. e ,end wh.d.t.,lbwmichii selfortheaughhie
ownemplo5 ox, n c h himprovemenwarenotintendedo ffertdforsale.lf, OC' ROUP RES.UNITS
h.wcvecth provemem ia.ald wilhinaneycar letinn,thcowner- {s/�
builder will lave uNen ofpmvmg that he did not h' or imp ve fur propose of
sale.), QTY. PLUMBINGI'ERMIT FF,E ,OODZ APN
❑ Uaso nero pmpery,annexclusively ratting with licensed conuacmn to
constmet t e project(Sec.1014,Business Professions Cade)The Contractors
License Ln r Joesnmapplytonnownerof perrywhobuildsmimprnvesthercoo,and PERMITISSUANCE
whornntru Is for such pmje.e with ac uactor(s)Iicensedpureuvnl to the Connnclo,a
License 1. v. ALTER-DRAIN&VIiNT-WATER(EA) ESUMMARY
❑ Tum xempt under Sec. ,B&P C for Nu reason BACK FLOW PROTECT.DEVICE OUTSIDE ES
SANIT Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT»
KMANCOMPENSATIONDI',CI.ARATION SCHOOLTAX Y N
❑ Ihercbyaf nmlh lhvvicecedifcate of consemmself-Insure,ora certificate of FIXTURES-PER TRAP RECEIPT»
Worken'Compcasation Insurance ora cenibed copy thereof(Sec.39M.Lab C.)which PARK FEE N
coversall employee's underthis permit GAS-HA.SYSTEM-I INC. OUTLETS A' WCFAPT»
Policy» B^IQP GICSION FEES
Company GAS-EA.SYSTEM-OVIM4 H1O PLANCHECK :E
❑ Cenifedcopykikerchyfumished. Sb
❑ Ccrtilied copy ie filed wiN the city inspection division. GREASIVINUUSTRL WASTE INTERCEPTOR GRADI �1- /�
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION
SOILS FEE 7
COMPENSATION INSURANCE
(This section need not he completed if the permit is for ons hundred m' dollen(5100) SEWER-SANITARY-S'rORM EA,200FT. F,NERCY FEE ,
orlcs.J
I certify that in the performance ofBe work for which this peit is issued,I shall WATER HEATER WMB
iNT/ELEC
not employ any person in any manner so as to become subject to the Workers PAID
Campensalua Lawsof Califomia. Data WATEk SYSTEM/TREATING Date Ret' 11
Q z Applicant
0 NOTICH TO APPLICANT:If,vfler making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. IAL:
t" 4 become subject to the Workers Compensation provisions oflhe Labor Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING IEE rl to
/
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE O
^a 1 hereby affirm thuuhem Is a construction lending agency for the performance ofCD
U O the work for which this .on is issued(Sec.3091,Civ.C.) ELECTRIC FEE /w
t-w Lenders Name
Lender.Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have mad this application and state that the above information is
correct.to agree to comply with all cit and ordinances and state laws mlatin to PERMIT ISSUANCE MECHANICAL ICA
6 pyhe yon rynr g
Uj abovbuilde-mentioned sager herebyauchodm representatives of thio cirymmner upon the
U
above-mentioned agree propenyfor lnspaand purposes. ALTER OR ADD TO MI3CH. GONSTRUG 'AX
(We)agree nt save,sant nify and keep harmless the Cry of Cupenst s against
liabilities,judgmrnhe I, anile ses which may in anyway nccme against City AIR HANDLING UNIT(TO 10,000 CFM)
n cons 9uence of the Branling of n AAOP
AIR HANDLING UNIT(OVER 10,01X1 CIM)
ignawrc of D' EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10(1,010 BTU) Date Receipt»
Will the applicant or future building occupant store or handle he urdom material
as defined by the Cupcn inn Municipal Cale,Chapter 9.12,and the Ilwhh and Safety HEATING UNIT(OV HR 1(X1,0(10 BTU) T
Code,Section 25532(a$n VENTILATION FANISINGLE RESID) I t
❑Yes ❑No
BOILER-COMP(3fIP OR IW,OIMI RTU) JUN
TE
Will the applicantor fwumbuildingcecupantumequipmentnrdwiceswhich emit tlU,V O� 1995
F gwdous air contaminate a defined by the Bay Area Air Quality Management BOILER-COMP(OVER i(k. 10 BTU)
rico t.
1 ❑ ❑
Yes No NEW RESIDENTIAL MIECH. SQ.FT. CIT�IIy UI- V Uf'OMNO
L
have read the haz.Nous..'crisis react..rns under Chapter 6.95 of Bm
alth&Safety Code,Sections 25505,25533 and 25534. 1 understand that
g dwx not che
he requimmenu which must be met prior to issuance of a Cmi0cate of
horized ntleat Data TOTAL: ISSUED BY:
OFFiCE