28210APPLICANT TO FILL IN INFORMATION WITHIN RED LINER. 111E RAI I onIIJT ocu nw v
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TTY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT � PLulxlnrvc- MecxprvlcnL
PERMIT No
28210
BUILDING PROJECT IDF.N'1'IFICATION
BUILDING ADDRESS:
SANITARY NO.
APPPUCATIONSUBMITTALDATE
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UNIT# LOT#
,
LJ
OW SN E. PHONE:
• CONT ACT R'S A E: LIC NO:
ARCH] ENG EER: LC O:
N/C CONTROL#
pp
CO A PH E:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
11 1:1 ElI'butI
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CONTRACTORS DECLARATIONAPPLIANCES
Thereby affi thmlam licensed underprovisions ofChepmr9 (commencing with
Section 7")hf mil 3 of the Business and Professio Code, and my license is in
full force and effe �rs (sem
License Cl ss Lic.# J .07S //
Date Coolraclor
PERMIT ISSUANCE.
- RESIDENTIAL
� ]OB ESC N
SQ. Ff. FLOOR AREA $/SIDIFT.
PANELS
UP T0200 AMPS
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op
W
ul
RCHITECTS DECLARATION
1 nderslan my plans shall be used as public records.
201 - I(10U AMPS
OVER 1 WO AMPS
SIGNS ELECTRICAL
Lmensed Professional
�rFit
a,
m
QSection7031.56y.nyapplicantf.ra
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_
OWNER -BUILDER DECLARATION
I hereby affirm Nat I am exempt from the Conlruaor's License Law for the
following maxed. (Section 7031.5, Business and Professions Cede: Any city or counly
which muld' v permir m conswcl, alter, improve, demolish, or repair any..mature
Prior to its issuance, also requires the applicant for such Permian file a signed statement
that he is licensed pursuant to the provisions oflhe Contractors License Law (Chapter
9(commencing with Section 9000) of Division 3 ofthe Business and Professions Code)
m
or that he is exempt landrona and the basis for e alleged exemption Any violation of
permitsubjectstheapplicuntloacivilpenaltyof
nt more than five hundred dollars (5500).
❑ 1,:mnwner.fthepropemy,ormyemployeeswithwagesasthei...I"ompereahm.,
will do the work, and the structure is not intended hall filled fortune (See 70414, Business
and Professions Cede: Tim Contractors License Law does not apply to an owner of
Property who builds or improves thereon, and who does such work himsel for thmugh his
own employees,provided.bat such imProvememsurenotimended.roffereJ forsale. If,
however, the building orimprovement is sold within one yearnfcomplelion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as ownerofthe property, uatex¢lusively coatmmingwithlicensed cnmmnom to
construct the project (Sec 9044, Business and Professions Cade:) The Chairs....'.
License Lawdoesnot apply man ownerofpmperty whobuildsorimproves thereon, and
who enotm.ts brsuch projects with acomractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOLE IC
VALUATION
f0/^i<r—
J V U
OUTLETS -SWD HES-PIXTIIRES
NEW AL ELECfR SQ.
STORIES
TYPE CONSTRUCfION
OCC. ROUP
M OZONE
RES. UNITS
APN
TO
QTY' PLUMBING PERMIT
P'RMITISSUANCE _
ALT -DRA &VENT-WATER(EAI
FEE SUMMARY
BACK FLOW PRO ECT, DEVICE
OUTSIDE FEES
Owas, Date
ITARY Y__N
RECEIPT It
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that) have a cenificvte ofeensent to self -insure, or a certificate of
Workers Compeasmion Insurance or anthill
arsell employee's under this penni4 Plhercof(S /3j8Q0/LebCJwhich
/
DRAINS -FLOOR ,R OF, AREA,COND.
SCHOOLTA Y N
RECEIPT #
FlSTORES - PER TRAP
P YN
GAS-EA.SVSTEM-I INCA TLETS
Policy#—�^� / n7)/
RECEIPT#
Company,l/� L/ ��t
BUILDING DIVISION FEES
LJCertified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
GREASFJINDUSTRL WASTE INTERCEPTOR'
GRADING FEE
CERTIFICATEMPEN ATIONINSUROM WORKERS'
COMPENSATION INSURANCE
GREASE'IRAP
SOILS FEB
(This section need not be completed ifthe permit is Forms hundred dollas($100)
or less.)
SEWER -SANITARY -STORM EA. 20fit
ENERGY FEE
I certify that in the performunce'If 'he an" forwhich this Permit is issued. I shall
no, employ any person in any manner so as m become subject m the Workers
Compensation Laws of California. Date
Applicant
WATER HEATER W/VENT/ELECTR
PAID
Date Receipt#
WATER SVSTEM/TREATING
NOTICE TO APPLICANT: If, after making.bis Certificate of Exemption, you should
bever. subject m the Worker's Compensation Provisions of the Labor Cade, you mus.
forthwith wmply with such provisions or this permit shall be deemed revoked.
NEW RESIDENTIAL PLMB. SQ. FT.
T
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constuniOnd lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
SEISMIC FEE
ELECTRIC FEE
TOTAL:
Lender's Address
1 certify that I have read this application and state .Mt the above informatihn is
hmecl. Ingreem yw hallcity and county Originates and state laws relating to
builJing constru on, and hereby emhnriu represenmtives of.his ciryroemerup.n Ne
above -menti d property for inspecti .poses.
(We) lee to save, indem Icep hurmless .he City o'C. a..
Cul.. -gains,
liabilitie, utlgmwns,..ets en .which may in any way accrue vgainst s -id City
ofthc grant xthis permit.
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,00tl CFM)
AIR HANDLING UNIT (OVER I0,000 CFM)
ignamre of Appl oil r1
EXHAUST HOOD(W/DUCT)
HAZARDOUS MATER LS SCLOSURE
Willlheap mard
maul or future building men t store or bundle hazaous material
as defined by 1 Cupertino Municipal C , Chapter 9.12, and the Hcul.h and Safety
Cale, Section 5532(.)9
PAID
Dam Receipt#
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER Ifift" BTU)
VENTILATION FAN (SINGLE RESID)
Yes
Will dm.Pplicantnrf I bul11 encu and ce
g p a qui pmcnlnrdeviceswhich emit
zwlous air comaminams asodefned h Bay Area Air Quality Management
islricl)
ISSUANCE T
py J
tl—
BOILER-COMP(3HPOR I00,000BT11)
BOILER - COMP 100,0(10 BTU)
❑ Year
NEW RESIDENTIAL MECH.—SQ. FT.
JUN
I have read .he hazardous mamuels requirements under Chapter 6.95 of the
Sections 25505, t itis .11111. 1 understand That
California building
lthdo & Safely Corecurrently my rsuanceoilitydift,ay the
overpaif the dofgdhepurcarion which
Occupant of the requirements which must be met prior, to issuance of a Certificate of
be met
Occupancy.
N 23 1
V j(�I-�ur;�`'
-- till
BY:
Owner or dully, --d agent Dale
TOTAL: ISSUED
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