28206 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, A A a�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL 1yV( L {V'
HW[.DING YROJBC'T IDENI'IFYCM'ION
ILD AD S: SANITARY NO. APPLICATION SUBMITTAL DATE.
�/�� e
kx UNIT# LOT
ER NAME: PHONE: C AC'TOR'S NA LIC O.
"I N/C CONTROL#
CIIITE /ENGINEF LIC NO: ADDRESS: / /! ❑
CONTACT': PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
yvZ Thereby affimidair l am licensed under provisionsol'Chapter9(commenting with
00 Section 7")of Division 3 of the Business and Professions Code,and my licence is in PANELS �/sg
y F full functional effect.
<,ZyW License Class Lie.p UPT02MAMN
h=y Date Conoacmr 201-1000 AMPS I
ZQNZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—❑ I understand my plans&hall be used as public records.
O'4�u SIGNS ELEGI'RICAL
SS<" Licensed Prafsisiunul
OWNER-BUILDER DECLARATION SPECIAL CIRCUFFMISC.
�0.�dd0 yF I hereby affirm that I am exempt from the Ceutowun',License Law harlot
u1LL�r<n following reason.(Section 7131.5.Business and Professions Code:Any city or county rTMP.METER OR POLE INST.
(:—y J which requires a permit to comwct.alar.improve,demolish,or repair any a oicame
E YE prior to its issuance,also requires the applicant for such prntitto files signed statement POWER DEVICES
Ap that he is licensed pursuant o the provisions of the Commcour's License Law(Chapter
I1commencing with Section 10001 of Division 3 of the Business and Professions Cock) SWIMMING POOL ELECTRIC VALUATION
Wroy ar that he is exempt dcrefrom and the basisfmlhealleged exemption.Any viulatinrof OUTLEfS-SWITCIiFS-FIXTl1REs
F.Zia Section'/031.5 by any applicant fora permit subjects the applicant m acivil Penalty of
mol more Ihun five hundred dollars($50().
C� [ILvnwrareftheproperty.ormycmpleyeeswith wagcaa9theirsolecompcmetion, NEWRESIDENf1ALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
63-- will do the work,and the soucture isnm intended oroffered for sale(Sec.7144,Business
and professions Cale:no Cornnecmr's License I.uw dura not apply to an owner of
properly whobuildsorimpmvesthereon,and whoducasuchwurk himxlfurthrough his
ownemployees,provided that such improvementsmanot imendeduroffefedfnrwle.If, OCC.GROUP RI?$.UNITS
however,the buildingor improvement is sold within one year ofouruld tion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for perform of
vele.).
❑ Las mourofthepropery,amexclusively contracting with licensed contractors or QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onstmct Om Project(Seo,7044,Business and Professions Cede:)The Contmctor'e PERMIT ISSUANCE
License Lawdoes not apply to an ownerofproperty who buildsorimpnwesthereon,and
who comment forsuch projects with a conme,ums)licensed puunottothe Contractees
License Law, ALTER (EA) FEESUMMARY
❑ I am exempt under Sec. ,B&P C for Nis reason O .ID
BACK FLOW PROTECT.DEVICE SANITARY Y N
a —Date—
WORKMAN
am DRAINS-PLOOR. r ,COND. RECF.IPI'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm Nat l have u certificate of consent o selLimure,orecertifica' of XTU ;R TRAP RECEIPT#
Woder%Cnmpcnsaion lnsumnce nraccnifiW copy thereof(Sm.Jglp,Lob CJ which PARK FTE Y N
coversall employees under this permit. GA EA.SYSTEM-I INC.40UTLE3'S RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenilied copy is filed whit the city inspection division. GREASFANDUSTIU,WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPa SOILS FEE
COMPENSATION INSURANCE
This section need not be completed iDhe permit is forces hundred dollars(SIM) SEWER-SANIT 300 ENERGY FEE
orless.)
I cenify that in the performance ofthe work for which this permit is issued,Ishdl WAt E I ENT - Iz.
net employ any person in any accom,
fle m to become subject to the Workers' PAID
z Compreastionlawaof Califen ia. Dam W STE TI G Dam Receipt#
Applicant
ZO NOTICE TO APPLICANT:Iffmr making this Cenifieum of Exemption,you should NEW RES ENTIAL FINE. Q.FT'. TOTAL:
E-' rA become subject to the Workers Compensation provisions of Ne Labor CW", .Lust
� > forthwith comply with such provisions or permit shall he deemed revoked. BUILDING FEE
W z CONS9'RUCI'ION LENDING AGENCY SEISMIC TLE
5 I hereby affirm thanhem is is conswaier lending agency further pinfornance of T ELECTRIC FEE
I..) O the work for which this permit is issued(Sec.3097,Civ.C.)
w r. lender's Name
PLUMBING FEF.
Leader's Address QTY. HANICAL PERMIT FEF.
V 1 cenify that I have read this application and state Nm the above information is
correct.I agree to comply with all cit and ninances and state laws relatin to PERMITISSUANCE MECHANICAL FF:E
b Pyhe city yo g
U Z buildi-mentinnd profnit herehyaethmim representatives of this city turner open the
YJ z above-mentioned propertyfor mnify and keep
ALTL'R OR ADD TO MECH. CONSTRUCTION TAX
(WE)agree m savq indemnify and keep harmless the City of Cupcnino against
liuhiliti ,'nd•meats,costs expo hi mayinanywnyaccructi'm ".idCity AIR HANDLING UNIT(TO lRM0CFM)
me n ter fthegrantingort s itcLe .
/' AIR HANDLING UNIT(OVER IB,BBO CFM)
Si,imme of ApplicanUContracm Dom EXHAUST HOOD(W/DUC) PAID
HAZ DOUSMATERIALSDISCLOSURE If EATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle herardous material HEATING UNIT(OVE0.100,tXk1 BTU) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12.and she Health and Safety
Cede,Section 23512(al?
El Yes 0 N VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the optician mrfmore builtlingoccupantuucquipmem ordeviceswhich emit BOILER-COMP(3HPOR 100,000 B"N)
wpp pp��
ecious air contaminants as defined by the Bay Ares Air Quality Management BOILER-COMP(OVER IOQpp99 000 BTU) {- A I D
isvia?
13 Yea EI No NEW RESIDENTIAL MHCH. SQ.FT.
1 have read the haysodous materials requirements under Chapter 6.95 of the JUN 22 '995
Culifomia I Icalth&Safety Calc,Section,25505,25533 std 25534.I understand that
if the building does not currently have a mount,that it is my responsibility to notify Ne
occupant of the requirements which must be met prior to issuance of a Cenificam of CI7 Y Ur UuiscH I u�
Occupancy.
Owner m authorized agent Dam 'TOTAL: ISSUED BY:
OFFICE