28405 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMITNO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL. .O /I O C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION #�L o 4 J
BUILDING ADDRESS: SANITARY NO. APPLICAUONSUENAITTALDATE
���°" UNIT# LOT H��K
WN S NAM - PHONE: CO RACTOR'S NAME: LIC NO:
N/C CONTROL N
• ARCHITECT/ENGINE LIC NO ADDRESS: - ❑
CONTACT: �Y/ PHON BUILDING PERMIT INFO
{jJ Q p QTY. ELECTRIC PERMIT FEE
e T E PIE MECH
rr...� O PERMIT ISSUANCE t� ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBES�CRIP`TION���•���p�\
QWZ IbembyafBmithatlamlicensedanderprovlslomofChapter9(cmmmencingwitM1 �J
l 0 0 Section 701mof Division 3 oft he Bminessand Professions Code,and my license is in PANELS Kr -V
�dEfull force and efiec s
License lass c.# siit1 UPT02MAMPS
vi Dale y� Contrae ��# 201-1000 AMPS RQ.FT.FLOOR AREA 5/SQ.IT.
Zo'iz - aaaf���R���jjj�iiITECTg DECLA A O OVER 1000 AMPS
0.Z O I understand my plans shall he used as public records.
t, SIGNS ELECTRICAL
2V Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
L 1 hereby afnn that I am exempt from the Contractor's License Law for the
u13 y following reason.(Section]031 5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to contract,alter,improve,demolish,or repair any structure
a ye prime.has lsamree,also reymires theapplicaat forsuch permit to file.signed smtement POWER DEVICES
41 Q'p that he is licensed pmsuenIto the provisions of the Comrecmrs License Law(Chapter
O SWIMMING POOL ELECTRIC VALUATION
0 9(wmmeN exempt therefrom
and
dt000)he Division Sof theBusinessexemption,
and Professions Code)
in that heisexb,.nerefromaadthebasis for the all thedexempti toacivipen ley of
Q
Section LS by any applicant forepermit subjects the applicant penalty of UTLETS-SWITCHES-FIXTURES
nm more than five hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ,FIL STORIES ION
wCw [I1,asowneroftheproperty,ormyemployeeswithwagesmtheirsolecompensation, TYPE CONSTRUCT
will do the work,and the straemreis not imendedoroffered for side(See.9044,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
property wholuilds orimprovesthereon,andwhodres such workhimselforthrough his OCCGROUP RES.UNITS
ownmployws,pmvidedthatsuchimpmvemcntsmnwimendedoroff=dfaysale.If,
however.the building or improvement is sold within one year ofeempletion,theowner- L:
builder will have the burden Mproving that he did not build or improve for purpose of
sale.). PLUMBING PERMIT FEE QTY.
❑ I,as ownernf theproperty,am exdusivelycontrecting with license)convacmrs t. FLOOD ZONE APN
..,,met the project(Sec.7044,Business it Professions Cale:)The Cra
.mcmds
License Law docsnot applyto aam
msomifppertywho builds orimprovesthereon,and PERMIT ISSUANCE
whocmntracts forsuch projects with ucotnractov(s)licensed pursuantmthe Convacwfs ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I atm exempt under Sec. ,B&P C for this reason BACK FLOW PITT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS- OOR,ROOF,AREA.COND. RECEIPT#
• WORKMAN COMPENSATION DECLARATION SCHOOL TA% YN
❑ Ihereby.ffirm that l have a ceniftcate ofcomentto self-insure,or a certificate of RECEIPT#
Workets'Comttie
pemition Immo eor a med copy formf(Sec.3800,Lab C.)which FI RES-PER TRAP PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# z BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(RA) PLANCHECK FEE
❑ Cenificde.pylsherebyfumished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASET P SOILS FEE
COMPENSATION INSURANCE
(This seaiii not becompleted ifthep.it is for.. hundouldo11 5100) SEWER- Y- RM EA. ENERGY FEE
mless.)
I certify that in one performance of the work for which this permit is issued, shell WA?JH WNENT FGeR
not employ any person to any manner an is m become subject t.the We a PAID
Compensation Lawsof Culifomis. Date AER SYSTEM Data Receipt#
O 'Z APPlicam
0 NOTICE TO APPLICANT:If,after making this Certificate of ExempIgn,you h.1,1. NEW 1 NTV!L B. Q.FT. TOTAL:
(~ f/J became object the Workers Compensation provisions of the Labor Code,you mut
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
QWQ Q CONSTRUCTION LENDING AGENCY SEISMICHE
fes' Z I hereby affirm thm there is a construction lending agency for the performance of
O the work for which this permit is issued(Sec 309],Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name PLUMBING FEE
u" F Lender's Address Q'Y. ME ANICAL PERMIT FEE
W I certify that I have read this application and state that the above information is MECHANICAL FEE
>" a correct I agree to comply with all city and county ordinances and state laws relating m ERMIT UANCE
t: lZIbuildingmnswction,and M1ereby authorize represemntivesof mixcity[o emerup.nthe CONSTRUCTION TAX
U 'Z above-meminned property for inspection purposes. - ALTER OR ADD TO MECH.
(We)agree m save,Indemnify and keep harmless the City of Cupertino eg.last
Iiabilltles,Judgments,costs and expenses which may in any way acerueagainmsaid City AIR HANDLING UNIT(TO IE01MCFM)
in to q f dv un permit.
I -, AIR HANDLING UNIT(OVER Io,OW CFM)
Signa re ofA licam/Commcmr •�e� Date EXHAUST HOOD(WMUCD
I PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO IW,1100 BTU) Date Receipt#
Will the applicant or future building.ccupwt store or handle hazardous materialHEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 255320x07 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATrT
WillNcapplicmtorfuturebuildingoccupantuseequipmentordeviceswhichetmit BOILER-COMP(3t{p OR 100,"BTU) p
. hazetdeas air contaminants as defined by the Bay Area Air Quality M...gemeal BOILER-COMP(OVER 100,000 BTU) AID
District?
❑Yes 12N. NEW RESIDENTIAL MECH. SQ.FT. J1f
I have read the hazardous materials requirements under Chapter 6,95 of the ` •ri V% 199
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
ifthe building does not
mentscurrently which most
his
etprirmyssuancsiofa responsibility me
occupant of the requirements which must a met prior m issuance of it Co notify
e
Occupancy.
Owner mauthorized agent Date TOTAL: ISSUED BY:
OFFICE