28398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
BUILDING-ELECTRICAL PERMITNO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT II)EN'f1EICA I JON 28398
BUILDIN//G��ADDRESS: B.+S. LxSL SANITARY NO. APPLICATIONSUBMTITALDATF.
A$/ a.il UNIT# LOT# IO6Uy
OWNERS NAME .1�-" PHONE: CON1TRACI'PR'SNAME: / '• LIC NO:
J r L1C1', g1aJ� IZ 3y �YN IVINILIN giq$ I N/C CONTROL#
RCHITECT/ENGINEER: LICNO: ADIRE
O. ox 362 Alta A -) I
CONTACT: PHONE: QTy ELECTRIC PERMIT PEE BUILDING PERMIT INFO
� /I BLDG ELECT PLUMB MECH
Joe V61� 0V PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL - TOB DESCRIPTION
9z thereby affirmthat Iamlicenseduncerprovistemsofatipter9(Commencingwith Re61�- 6011 SCI Ae,,J $�e..e
ta100 Section]000)of Division 3 of the Business and Profession%Code,and my license is in PANELS 11
Fyd full force and effect, p UPT021N)AMPS SIR✓ ,,Cl Re+-e. r6R-
¢F Z License Class Lic.# 1 8 ) r
so<y Date Convector 201-IQ'10 AMPS SQ.FT.FLOOR AREA $/SQ.Fri.
Fy,T� A CHITECTS DEC ATIO OVER 1000 AMPS - ✓H rI
ZO o.O I understand my plans shall be used as pub m'cords. 4)(u Qp
rqu, - SIGNS ELECTRICAL
,� Licensed Professional 1
yFZ
OWNER-BUILDER.EC,Cmatm ON SPECIAL CIRCUIT/MISC. 1
OyFI hereby affirm that I am exempt from Ne Contractor's License Law for the
following reason(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. ;
f4J which requires a permit to construct,alter,improve,demolish,or repair any structure
ori
�y� prior to its issuance,also requires the applicant forsuch permit to rile a signed statement POWER DEVICES
ot
C Nhe is licensed pursut m the Provisions of the Comfam r,License Law(Chapter
0.
anHVALUATION
W 9(oommencing with Section 7001 of Division 3 ofthe Business and Professions Cada) SWIMMING POOL ELECTRIC
ty❑ot or that he is exempt therefrom and the basis for the alleged exemption.Any violation of � l0
F„ ¢ y y applicant pc I t sapplicantPene y m OUTLETS-SWITCHES-FIXTURES S
i• Section]03 L56 en fora 'mit subjects theree civil I[ f 7
of marc than rive hundred dollars(5500).
p NEW RESIDENTIAL ELECIR _SQ.Ff. STORIES TYPE CONSTRUCfION
❑ I,asowneroFlhe property.ormy employeeswith wagesastheirsolecompensaion,
p, will dothewons and the he Contractors License
Law
of apply]1144,Business
end Professions Code:'I pr Contractors Licence Law does not apply to an owner of
propertytyess,providmproventhereov,andwhodceasuch workhimsfiered hrough bis OCO GROUP RES.UNITS
wnemployee,providedthatsue improvementhin we
tiear ofso pletio ,theo nIf,
however,the building or improvement is sold within oae year of completion,thepose of TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,ct the M,thepmpertgum Business
ss and Pont .int, Wc:)no nvacmrsrs
Livers ct the project(gee.o ano Rosiness and Professions CWc:)The Contractor's PERMIT ISSUANCE
Llcenselnw doeanotapplym anownuofpropenywho builds mrlmpmves thereon,and _
whoconvacts forsuch projects with acontmcmr(%)licensed pursuant to the Contractors ALTER-DRAIN&VENT�WATER(EA) FEESUMMARY
License Law.
❑. 1 oro exempt under Sec. ,B&P C for this rtazon BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
RECEIPT'#
Owner Date DRAINS-FLOOR,ROOF.AREA,COND.
SCHOOL TAX Y_N
WORKMAN COMPENSATION DECLARATION
t�I hereby affrm that I have a cenificum ofcoaaent to self-Insure,ora certificate of RECEIPT#
kers'Compensation Insurance ora certified copy thereof(Sec.3800,Lab C.)which FIXNRPS-PF P PARK FEE Y N
overs lle IAoty up c this pe 't -Ep.SYSTEM-I INC.40lITL S rL RECEIPT#
Policy.11
` BUILDING DIVISION FEES
Compmy Ae -7—' GASGAS-EA.SYSTEM-OVER PLANCHECK FEE
9 CerfFa copy is hereby famished.
� Certified copy is filed with the city inspection division: GREASE/INDUSMI.WASTE INTERC PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKE GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need aorbe completed ifthe pertnitis forene In dreddollam($100) SEWER-S IT,.RY-STORM EA.200 ENERGY FEE
or lase.)
I certify that in the pecoommnce of the work for which this pe it ie issued,I shall (W A RWNENT/EI. f�
of employ any person in any manner so as to become sable t to the Workers PAID
Compensation Laws of Califomia. DoteWA STE EA Dam Receipt
O z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exe ptioe,you old EW REST 1 BOMB. SQ.FF. TOTAL:
became subject m the Worker's Compensation provisions of the Ln r Cod�cd
forthwithcomply with such Provisions or this permit shall he deem¢ rcv0 I BUILDING FEE
(� CONSTRUCSEISMIC FEE
z1 hereby affvn that there is a conswction lending agency fur thcT AL: .. ELECTRIC FEE
Ne work for which this permit is issued(Sec.309],Civ.CJ
". Lender's Name PLUMBING PEE
u" F Lender's Address QTY. ;M IANICAL PERMIT - FEE
FUkI I certify that I have read this application and moth
the above nformmion is ' MECHANICAL FEE
L1s correct, Iagree to comply with all city and county ordic=andsone, 'sma:iigro PERMI SSUANCE
buildingconstmction,andherebyauthoriz mpmuntatives ofbuscitymc her
upon Ne CONSTRUCTION TAX
V 7 move-mentioned property for inspection Fortune, -RORADDTOMECH.
G7 (We)agree m save,indemnify and keep harmless the City of Cupenin most
liabdities,judgments,costs andexpenses which may in mywayeccrve ugainsr/i AIR HANDLING UNIT(TO 10,000 CFM)
consequenelfthis Penni 'l to
AIR HANDLING UNIT(OVER 10,000 CFM)
m azure of pplicnnl/Contmd��p ham EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,00)BTU) Date Receipt a
. Will the application'future building occupant score or handle hazardous matenal HEATING UNIT(OVER IW,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(¢)4 VENTILATION FAN(SINGLE RESID)
❑Yes 6Lkl- - ISSUANCE DATE
Will theapplicantorfuturebuildingaccupantuse equipmencordevlceswhichemit BOILER-COMP(3HP OR 100,000 BTU)
heaurdoos air contaminants as defined by the Bay Area All Quality Management BOILER-COMP(OVER 100,000 BTU) P A IM
District?
❑Yes rl rl
No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the JUL 14 1995
California Health&Safety Code.Sectiors 25505,25533 and 25534.I understand that
if the building does not currently have a locant that it is any responsibility m naify the
occupant of the requirements which must he met prior m issuance of a Certificate of CI I Y yr vurr m I 1114L7
Oc upnncy.
yfir
O o,au prized agent TOTAL: ISSUED BY:
OFFICE