28406 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT N0
. as'2y8 a,�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 6
BUILDING PROJECT IDENTIFICATIO
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
2 LOT N —�
OW MF� CONT 'SN E: CG jLICNOjP :
(� II/Y445/p_ N/C CONTROLp
RCIIISLCT/ENGINEER: LICNO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG P SCI' PLUMB MECH
PERMIT ISSUANCE. ❑ ❑ 1)
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL q JOB DESCRIPTION
MWz Iherebyaffirm Natlamlicem dunderpmvisionsofa.pur9lcommeneingwith
P4 Z O Sectionve rma of Oivi.ion 3.1'the Boulevard Pmfessinns Cade.and my license is in PANELSfirI
C tLuuppJJ]
License
Claws feet.
< License Clan Lic.N UP T021KIAMPS
yF-QN Date Contractor 201-IOW AMPS '
ZOv7yi 2. ARCHITECTS DECLARATION OVER 1000 AMPS SQ,IT.FLOOR AREA E/SQ.FT.
CZ-0 1 understand my plans shall be recd m public records,
P res L X SIGNS ELECTRICAL
4��dd�� Licensed Professional
Sy pd< OWNER-BUILDER DECLARATION
3 O SPECIAL CIRCUIT/MISC.
�Maq5u I hereby affirm that 1 am exempt tram the Contractors License law for the
m In following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
(: m which inquires a permit to construct,mut,improve,demolish,or repair any structure
prior to its issuance,alsorequires the opplicam forsuch permit to file a signed statement POWERDEVICES
qe that he is licensed pursuant to Ne provisions ofthe Commumex License Law(Chapter
9(commeneing with Section]000,,'Division Saddle Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
y)_y or that he is exempt dumfound and the basis for the alleged exemption.Any violation of pIJTLETS-SWITCHES-FIXTURES
Za Section 9031.5 by any applicant fora permitsubjects the iolicmt m a civil penult,of
not more than five hundred dollars(SSW).
CI 1.mownerofNe Wop ny,ormyemployceswiihwagesastheirsolecompensatiun, NF.W RFSID[JJTIAL ELF.CfIi _SQ.Ff. STORIES TYPECONSTRUCLION
x322 will do the work,and themuctate is an,imeadedoraffam!I...to Ser.704,1.Business
oral Professions Cade:The Contractor's License Law does not apply m an towner of
property who builds or improves thereon,and who does such work h i rase If m through his
own employees,Provided that such improvements sure not intended oroffered for mle.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yeurofcompletion,the owner- T
builder will have the burden of flowing that he did not build or improve for purpose of
sale.).
❑ I,mownerofthepmpeny,amexcluslvelycontutingwiihlicensedcono- tomo QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
common,the project(Sec.Il44,Business and Pmfessinns Cade)The Contractors PERMIT ISSUANCE
License law does not apply tom ownerof pmperty who builds or improves t hereon,and
whomntrac,s(orsuch projects with a contractors)licensed p nouant to the Contractors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE E.
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND, RECEIPI'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsem to self-insure,or a certificate of FIXTURES-PER TRAP. RECEIPT
N
Workers'Compensation Insurance oracertified copy thereaf(Sec.3800,Lab C.)which "� PARK FEE Y N
covers all employee's under this permit GAS-EASY - NC.40IITLIiTS RECEIP #
Policy p BUILDING DIVISION FEES
Company GASrEA,SYS tMR4(FA) PLANCHECK FEE
ID Certified copy is hereby furnished.
❑ Cenif¢d copy is filed wi@the city inspection divisiaa FASE9NDJSTRLWA TH INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' Q \ ft I ' GREASETRAP j SOILS FEE
COMPENSATION INSURANCE ...,,,AAA
(Thissotion need not hecompllam ifthe permit is form!hungcudollari S IW) SEWS TORM EA.2WFT. ENERGY FEE
mles") ` '
I certify that in the performance ofthe work for which tld\pertnn uissuW,[.hall q'� IFER WIVENT/ELECfR
nm toy ,'croon in any manner ro m to become subject to Ne Workers PAID
En soon Z fcnlif9gmv�. Dat / ATER SYSTF.M/IREATING a ReceiM N
0 tic t s. 27
z N I..T �LICANT:If,afterr making this Certificate of Exemption,ynus told NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
p become su lectlothe Workers Compensation provisions ofthe Labor Code,you must
a forthwith comply withanch provis' a;to this permit shall be domed'aVdked. BUILDIN -E
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a I herchyufGrtn that there ism comms uction lendingngew,for the perf.extf TOTAL: ELLCfRIC
U O the work far which this permit is issued(Sec.3091,Civ.C.)
Lender's Name
FEV 1c;
1
U. noFE
correct.
QTY, MECHANICAL PERMIT FEE PLUMBI anE W I certify that 1 have read this application d sue that the above information is MECH NICAL FEE
l agree to comply with all city and county ordinances mdstale laws relating to PERMIT ISSUANCE
building construction,and hereby authorio rcpresenwtivssofthis city mender upon the CON UCf10N TAX
ulwve-metdionad property for inspection proposal.. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and keep harmless the City of Cupertino against
limilitics,judgments,costs andexpeteaswhich may in any wayaccme against sai City AIR HANDLING UNIT(TO 10.000 CFM)
in on nonce of the granting of t toss N it.
AIR HANDLING UNIT(OVER 10.000 CFM)
5 newrc of Ap Commcmr Date EXHAUST HOOD(W/DUCT) PAID 1 -
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0110 BTU) as I Receipt#
Will the apparamor future building occupant store or handle haaandous material HEATING UNIT(OVER IGI,(Np BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Coda Section 25532p)?
❑Yes ❑No VENTILATION FAN(SINGLE.RESID)
ANCE DATE
Will thea licantorfumre buildin aceto antuse mrdevias which emit BOILER-COMP(JHP OR 100,g100TU)
ISSU( hamrdous air contaminants as defined By the Bey Area Air Quality Management BOILER-COMP(OVER 1011,000 BTU)
Districts ❑Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. PAID A
1 have read the Intrusions materials requirements under Chapter 6.95 of the JUL 18 19^
Californ255
ia Health&Safety Code,Sections M05,25533 and 25534.1 undersand that a7
if the building does not currently have o tenant,that it is my responsibility to notify the CITY mention,of the rryuirtments which must be met prior to iasuwce of a Certificate of !sr
Occupancy. V (d
v
Owner or mthonud agent Data TOTAL: ISSUED BY:
OFFICE