28266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMIT NO. ^ /�/�/N /�
CITY OF CUPESIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL L VX L Vh I6
BUILDING DIVISION 'BUILDING PROJECT IDENTIFICATION t ' -
.LDINGADD ESS: SANITARY NO, APPLICATION
SUBMITTAL DATE
`
ILOT is
OWN' S E: PHONE: COTRACT ME: LIC NO: . v_
r
N/C CONTROL.#
' TEC IE GINEER: WC NO: ADDRESS:
CONTACT: PHONE: , BUILDING PERMIT INTO
QTY. -,` - - ELECTRIC PERMIT T' PEE; r';
BL
ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
O rL 2 I hereby affirm that am licensed under provisions of Chapter 9(commencing with
Pi,00 Section]000)of Division 3 of the Business and Professions Code,and my l icense is in PANELS -
yr�`� full foreeand effect.
GG'yZ License Class Lia# UP TO 200 AMPS
F
'n D m ue Dare - Contractor 201-1000 AMPS
FARCHITECTS DECLARATION SQ.IT.FLOOR AREA $/SQ.FT.
I understand my plans shall be used asps cards. EVER IOW AMPS
0z_Q
O z'..O SIGNS ELECTRICAL '
dh
License)Professional
Professional rtE�6 OWNER-BU ERDECLA ATION SPECIAL CIRCUITIMISC.
'Op,V I hatch,than that I am rapt form the Ca tractor's License Lew for the
W 3 k m
following reason.(Section 703 . ,Business and Profess ns Code:Any city or county TEMP.METER OR POLE INST.
(?]ae which requires a permit m nalmat,alter,improve,dem lisp nt repair any structure
ceY� priermisuance,a): thea litvntforsuch 'Oofilessinedamtement POWER DEVICES
yuires PP Pe g
yQO that he is license SsuanuomepmviaimmoT the Contract s License Law(Chapter
d�o 9(atmmen with Section]000)of Division3ofthe Buaine end Professions Coda) SWIMMING POOL ELECTRIC VALUATION
W e rn nacho 131.5 by any applicant
nt f the permit subjects
is the app tion.A ivil penally of OUTLETS-SWITCHES-FIXTURES
C Semio ]03L5 by any applicant for a permit eubjocts thceppllc t m o civil pandit,of
not mor thanfivehundreddnllan($5 ).
mm � ❑ Las w eroflhepropeny,mraye to agesasthei olecomNEW RESIDENTIAL ELECTR _SQ.FT.pensmime. STORIES TYPE.CONSTRUCTION
p, wi11dmhe otk;andt struem roReredforsale( 9044,Busineas
and Profess) ns Cade: e m no', top Lew'does tot ply o an ,..at of
property who uildsori p' ,anJ whodoessuchw himsdfarthrmugh his OCC.GROUP RES.UNITS
employed pr Improvememsaremaint dedorofferedforaile.If,
Lowevegthe bu dingori pr ementisscldwifhin one ofcompletion,the owner- TOTAL:
builder wil I has the burd ving that he did not wild or improve for purpose of
s❑ )I,wownero beproperty,amexcluslvely c trotting with licensed count mc[o t QTY, ,' , , PLUMBING PERMIT Ei ¢s# - FEEI- FLOODZONE APN
s• k ,it .Y- kwtcutw
construct the proj t(Sic.7044,Business an Professions Coda,)The Contractor's -
License Law doespo applymanowshermE enywhobuildscrimpmvesthrommand PERMIT ISSUANCE
whocontmctsforaeei rolectawnhasen[r torts)licensedpunuamtome Gmtracfoes -
License Lew. ALTER-DRAIN&VENT-WATER(EA) ''?}"5?i z g[PEE SUMMARYS g.,�,;(}
❑ I sm exempt and, ce. B&P C for this reason BACK PLOW PROTECT.DEVICE OUI SIDE PEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. - RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affrd that l have a certificate of consent to self-insure,or a ceniftcate of FIXTURES-PF:R TRAP RECEIPTN
arker%Compensation Insurance or a certified copy thereof(Sea 3800,Lab C.)which PARRPEE Y - N
coven all employee's under this permit. GAS-EA.SYSTEM-i INC.4 OUTLETS RECEIPT#
Policy BUILDING DIVISION FU
Company GAS'EA.SYSTEM-OVER 4(EA) PLANCHECKEEP
CI Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. - GREAgFJN'DUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OFEBEMPI'ION FROM WOR RS' A n 1p( y1' dREA$E TRAP SOILS FEE
COMPENSATION INSURA nYl /A-� t [�•
(Thissectloumoe4not becompletediflhepennitis rond'handmaid ($100) �t 'SEWER S�NTJ'ARY-STORM EA.2WFU ENERGY 17EE
or less.) s
I certify that in the performance of the work for wld��!'t^hI,permit is issued,lsholl �"r WATE H ER LECTR
•
not employ any person in any manner so as m bexuCOe'ubjea to the Workers' PAID
Compensation Laws of Califomia. Date TER YS ^ G Date Receipt#
OZ Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of xemption,youshould NEW RESIDENTIAL PLMB. SQ ET. TOTAL:
f0, become subject to the Wooer's Compensation provisions of the Lahr Code,you must
Q forthwith comply with such provisions mthis permit shell he deemed revoked. BUILDING FEE �>
a CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that them is a coelion lending agency for the performance of
U O the work for which this permit is issued(See 3097,Civ.CJ TOTAL: ELECTRIC FEE
Lender s Name
Lenders Address QTLY--� MECHANICAL PERMIT ,PEE;:�`r PLUMBING FEE
� U
1 ten fy that I have read this application and state[list the above mfmtmehm is
�" a c tact I agree to comply with all city and coomyordmates,and state laws relating to PERMITISSUANCE MECHANICAL NEE
building construction,and hereby authorim representatives ofthis city mender upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and k^harmless me City of Cupertino against
liablllII 'udgmena,00 d penes mnymany we awruevgainntsuid ity IR IIANULINO UNIT(TO 10,00)CPM)
in cc c of fmi
I� AIR HANDLING UNIT(OVER IO,OW CFM)
gas mofA icanVCantmdtor (A D e EXHAUST FOOD OODUCT) 7
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardaus material HEATING UNIT(OVER 100,(0,0 BTU) T
as land by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectimt 25532(x)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
WiII tan,aplicamo rots a building by the
Area Air Quality andwhich, emit
BOILER-CAMP(3HP OR 100,000 BTU) ISSUANCE DATE
istNtus via conraminan[s es defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,ODOBTU) "
District? W A
❑Yes ` ❑No NEW RESIDENTIAL MECH, SQ.FT. 9"
1 Use rend the harardws materials 5505,255 3a under 34,1 un east of the JUL
California building
dM1&Safety Cale,Sections 25505,25533 and responsibility
I understand that VvG
Ifthe bnt oft he res not quirements
ly have a which
a [hath is my rsuanceoila tonotifyme Cii
occupant y,me requirements which mus[bo mat prior to issuance of a Certificate of ,.
Occupancy. L✓r I
Owner or amhoneed agent Dnte TOTAL: ISSUED BY:e U
OFFICE