25339 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO Bml, 'G.M1. PERMIT"°'
APPLICATION/PERMIT PING PROO-MNIDENHFIAI. 25339
BUILDING DIVISION ItW(.UINO PROJRCI'111KN"I IF'ICATION
BUILDING ApDRESS:� SANITARYNO. APPLICCAATON SUBMI'TTALDATE
00Irl I • Rp LOT is [,
OWNS Ram sts CONTRACTOR Erg
: LIC O:
NIC CONTROL#
ARC :T/ENGINEHILL ': ADDRESS: ^ ❑
CONTACT: • PI{O E:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
pyz I herchyuffirmthm lam doemedunderprovisi....fChapter 9(commencing with
00 Section'AI00)of Division 3 ofthe Boston.,and Professions Code,and my license is in PANELSfullf.ro
License
Clwad effect.
Up TO 200
yQd DolCls Con Hector 201-II"A PSS '
F'Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA SISQ.FT.
Z O y— I understvrd my plans shell be used as public ordl
recs. OVER 1000 AMPS D IN 1
GOZ Fp_.W SIGNS ELECTRICAL
yp Licensed Professional i
WX OWNER-BUILDER DECLARATION SPECIAL CIRCUIT(MISC. 9 I� II PUT
T
°0' 1 hereby affirm that 1 um exempt from the Contractor's License Law for the d�a V tl
W3wm following meson,(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST.
which requirts a permit to constmet,alter,improve.demolish,or repair any stmclt mG
pnormitsissuance,also requimstheapplicant for such Permittofileasigned statement POWER DEVICES E
0 O that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
a e� 9(commencing with Section 7")of Division 3 of the Business and Professions Cole) SWIMMING POOL ELECTRIC VALUATION
yYj_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F. Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
^� Ca
our more loon five hundred dol lets($5(10).
rop ❑ I,asownerofthepmNny,ormyemplomwithwagesestheirsolecompcnution, NEWRESfDEN'RALELECIR _SQ,PT. STORIES 'TYPECONSIRUCTION
3— will do the work,andthe structureis not intendedoroffcred forsale(Sm.7044,Business
and Professions Code:The Commctor's License Law does not apply to on owner of
property who buildsor improves themn.and who does such work himselforthroughhis OCC.GROUP RES.UNITS
nemployas,provided thatsuchimpmvemenm=notinteMM oroffesed forsele.If.
however.the building or improvement is sold within one yearofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for pur,mm of
ole.).
❑ I,uownerofNepropeny.am exdusivelycnmmcting with licrnmd contracmmo QTY. PLUMBING PERMIT FEE. R.00DZONE APN
construct the project(Sec.7044,Business and Professions Cmhe)'Me Commnor'a PERMIT ISSUANCE
License I aw does not apply to an owner of progeny who bei Id s or improves thereon and
whowntmets fm such pmjects with acommi Emitted pursuant to the Convector's ALTER-DRAIN&VENT-WATGR(EA)
License L.O. FEE SUMMARY
❑ 1 em exempt under Sec. ,U&P C far this rtavon BACK FLOW PROTECT,DEVICE SANITARY TY - E N
Owner Dat. RECF.IPI'p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION OWNS YN
❑ Thereby affirm that l have a cenificate ofconsem to self-insul..ora mni0cmeol � RECHIPTa
Wmkns'C°mpertsatier lnsumnre or a certified copy thereof(See 381%1,Lids C.)which RXTURES-PER TRAP Lit! PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM- INCA OUTLETS RECEIPTp
Policy M BUILDING DIVISION FEES
Company GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division, GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nolbt completed lfthe permit is Intone hundred dollars(SI007 SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performenceof Ne work for which this permit is issued,l shell WATER HEATERWNP.NT/ELECTR
not employ any lemon in any manner so az to become subject a,1be Workers PAID
z Compensation Lawsof California. Date WATTiRS T!?M/IREATING Date Receipt
Applicant
z��z-I 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you,houId N ESIDENTIAL PI.MB. SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions ofthe labor Cedgyau must
ttY forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a I hereby affirm that them is a construction lending agency for the performance of
Vr- the work whi
for ch,his permit is issaeA(Sec.3097,Civ.C.) ELECTRIC FEE
w I<ndce.Nam e
� .`+ Lender's r s QTY. Mf?CFIANICAI.PERMIT FEE PLUMBING FEE
L) 1 Wily at 1 have reed this epplicnian and torte Net a.above information is
co .lag etoconrply with all citymdcoudyo waren,sdynoenterti ing to PERMIT ISSUANCE MECHANICAL FEE.
.Fi buil agco Iructiourand herebyomhoriurepowe _b so(this rl5y to cmeru - CONSTRUCTION TAX
U `Z a e-m in propenyr, iw1rolion puryo ALTER OR ADD TO MECIi.
( )a turn, indemnify end keep I s the City of Cu inn 'surto
In it' es,j menlsemossinde,,' cswhich a nanywayacerue costs id City AIR HANDLING UNIT(TO 10,"CFM)
in nee the r ing th reit.
AIR HANDLING UNIT(OVER 10,(M CFM)
Signatumof Applicant/ cntramor ate EXHAUST'HOOD(WNUCI')
PAID
I ZARDOUS MATERIALS DISCL U L HEATING UNIT(TO 100,000 BTU) Data Receipt#
Wi111he vppli mnrfatme huiWing xcuFlut smon
Jle henardous material HEATING UNIT(OVER IW,OW BTU) TAft
es Jefned by the C penin°Municipal Cade,Chapter 9.12 e d the Health end Safety
Cade,Section 25532bd? VENTILATION FAN(SINGLL RGSID)
❑Yes ❑No
BOILER-COMP OR l0o,00(t)BTU) UppN EDATE
Will the applicant or fictum buildingattupunl useWuipmcmordeviesswhichemit M'
leaanMom air commandments as defined by the Bay Area Air Quality Management BOILER JUL
11 No
(OVER IW,00B RTU) fl0�pp f�� 199
District? R7
❑Yes Na NEW RESIDENTIAL MECH.—SQ.Ff.
I have read the hanardous materials requirements under Chapter 6.95 of the ^'w, u� J 3
Culdomia health&Safety Code,Sections 25305,25533 it 25534.1 undesland tout b 'ys
if the building does not currently have a tenant,that i1 is my responsibility to notify the VVI-Cf1 J IJ
occupant of the requirements which must be met prior to issuance of a Cenificam of
Occupancy.
Owner or amhnriud agent Date TOTAL: ISSUED BY: