28296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'1'NO. ^ ora ^ �a/N
APPLICATION/PERMIT PING PROJECTIDENTIFIC L t8 L a9 hV
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDIN ADDRESS: 22� SANITARY NO, APPLICATIONSUBMUTALDATE
7113 9 /�Q 11<�I, /1T// UNIT# IAT#
OW RS NA ' PHONE: CO RACT R'S NAME: LIC O:
CO
N / N/C CONTROL N
ARCHITECUENGIN LIC NO: AD S: ❑
T� vez e d!/e, S
CONTACT: PHONE: BUILDING PERMIT INFO
' QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El 1:1 ElLICENSEDCONTRACfOR'SDECI.ARATION APPLIANCES-RESIDENTIAL JOB DES RI�N_ _
xz Thereby apparitionviion 3 ofth Busimeerpr.v rfesions Code,and
mmecense with
�00 Semian 70110).[Diviainn3of the Business and Professions Code,and my license is in PANELS � /�
�z full forceC 1and effect //Q /_ !/ UPT02MAMPS
Q License Lick CO Cl 7 ��'L�
rtii,,oo Dae _Contractor OVER 100 AMPS
Z Or-i M ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT A SQ.FT. .
O Z�❑ 1 understood on,plans shall be used as public records. V
P.25 SIGNS ELECTRICAL `
qQ' Licensed Professional
ESa' OWNER-BUILDER DECLARAT SPECIAL CIRCUIT/MISC.
OaF 1 hereby afPind that I am exempt from the mors Lice se Law for the
W3�to following reason.(Section 703 I.S.Business ofeedi.ns Code:A yciry or county TEMP.METER OR POLE INST.
which requires a permit t.construct ,improve,demolish,or rep it any structure
niormitsissuanco,also requi eappliwmforsuchperman.filea 'gdedsmer,at POWER DEVICES
M O that he is licensed pare to the provisions of the Commemr's Llce.s Law(Chapter
Wy �S 9(commencin ection 7000).[Divisme 3o1fitho Business and Pro essi.ns Code) SWIMMING POOL ELECTRIC VALUATION
ort t e is exempt therefrom and the basis for the alleged exemption,A violation.f OUTLETS-SWITCHES-FIXTURES Iia �/w/�--_~
QSee on 9031.5 by any applicant for a permit subjects the applicant to a ci it penalty of 1177T1 M50
not melhanfivehundreddollars($5 NEW RESIDENTIAL ELECTR SQ.FT.
❑ Las.wneroflaboorperry,ormyem to 9Crithw esastheirsoleco Number, STORIES TYPE CONSTRUCTION
D, will othew.rk,andt estructa 'sa redforsale(Sec.70 Business
nA answers Cab Th m ac r' Law does nal apply to an wner of
pro rywhohuilds vs ..,.it who does such w.rkhim rah oughhis - OCC GROUP RES,UNITS
e ployees, uchimprmoursotsibromimende offered[.sale.lf,
no ,thebuilding ri provement is sold within one ye completion,[heowner-
builtler llhavethe be nofpowingthathedidno td or improve for purpose of ITo r�
oJ.
❑ Las erunheproperty'arnexcharo, onnanmg with licensee c.mmctore to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
msmnc[th�preject(See.9044,Buain . and PnvExuons Code)The Cmrnow is
License Law ce notapplymanove ofpsopeny who buildsorimproves thereon,and PERMIT ISSUANCE
whocontmet forsubprojects acontrachubd licensed personal bathe Contractor's ALTER EA
License Law ( ) FEE SUMMARY
❑ I am ex mph call ea ,B&P C for this reason BACK FLOW PROTF. .DEV OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOORRO REA,COND. RECEIPT#
,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX YN
❑ ffi
I hereby arm that l have.certificate ofconseram selbi also'' it culdicate of FI%TURES-PERT AP RECEIPT#
Workers Compensation Insurance oracertified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covets all praldysebun73' nb77 9 (_ GAS EA SYSTEM-]INC.4OUT S RECEIPT#
Policy It x.-33 (( //, 7 .1 BUILDING DIVISJOILft.S
Company ;Cf GAS-EA.SYSE -OVER ) PLANCHECK IEE
EICentficdcopyhsbeicbyfumished.
❑ CenifieJ copy is fled with the city inspection division OREASF✓INDUSTRL TE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBTRAP SOILS I E
COMPENSATION INSURANCE A7 V
(This section need not he completed lithe permit is for one hundred dollars SIM) SEWER-SANITARY- RMEA. ENERGY FEE
in Ioa.)
I certify that in the Itself n.....f the work for which this permit is issued,Ishall WATER HEATER N
not employ any person in any manner so as to become subject to the Workers' PAID Ac
Compensation Laws.[Califomia. Date WATER SYSTEM/1'REATIN tc eceiptk
1zZ Applicator O O NOTICE TO APPLICANT:If,after making this Caddied,of Exemption,pion,you should NEW RF.SIDP.NTIAL PLM,. SQ.FT. TOTAL:
i f�q become subject m the Worker'aCompensation provisions mile Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE +�
W Gz CONSTRUCTION LENDING AGENCY SEISMIC FEE
.GJ^ I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC PEE
the work for which thio permit is Issued(See.3097,Civ.CJ 9
V Lenders Nome
O.F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE '
L) I certify than I have read This application and state that the above information ie
correct.I agree to comply with all city and county num uncesand store laws rellongt. PERMITISSUANCE MECHANICAL EE
(� building construction,and hereby authorize represemmives ofthis city to toleration the CONSTRUCI'1 TAX
L) above-mentioned poll for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of ClImaor. airet
liabilities,judgments,costs andexpenses whichmay in any wa cru againsis rd it AIR HANDLING UNIT ITO 10,IXp CFM)
inconsequence of the,, lhgof�ddu.
/7/C/ AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applic Comment, ate V EXHAUST HOOD(W/DUCf) PAID
HAZARDOUS MATERIA DISCLOSURE It
HEATING UNIT(TO 100.000 BTU) Date Receipt
Will the applicant or building occupant store or handle hazardousmateriel
us delined by the Cupertinon Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOO,OW BTU) TOT
Code,Section 25532(.)1
❑YesVENTILATION FAN(SINGLE RESID)
No
ISSUANCE DATE
WliDhea Ileum or future building anmsee entordeviceswhich emit BOILER-COME(3HPOR 100,000 BTU)
pp gby h qe.A P pp
uzareoue air cumaminana os Aefnetl by the Bay Arce Air Quality Management BOILER-COMP(OVER 100,0110 BTU) 4
Distrinl ,D
13 yea (VN. NEW RESIDENTIAL MECH. SQ.FT. QIG 0
I have read the hazardous materials requirements under Chapter 6.95 of the Ci
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that t� / f
if the building does not currently have a tenant,that it is my responsibility to notify the l
occupant of the requirements which must be me[prior m issuance of a Certificate of
ccupancy.
0
Owner or authorized agent Dore TOTAL: ISSUE Y:74
OFFICE 11.1