28407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO n ILDI 4-F.Lf:CTRICAI. - PERA111'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIN0.MF.CNANICAI. n O /I O
Q BUILDING PROJNf-'I'111R.N1'IF'ICATION G o Gf
BUILDING ADDRESS: - SAN)IARY NO, APPLIG'f101N tiUBMHTALrDATE
— 'l 7
:ONITg LOT M
O NER A 1 PHONE: GWCI NAME: I LIC NO: NIS] CON'TROLM
06� 7
R0 IITECI'/ENGINEER: LIC NO: AD VCI ElON'I'ACI': PUONE:
QTY. ELECTRICPERMI'I' FEL? BUILDING PERMIT INFO
PERMIT ISSUANCE. ❑LDG ELECT PLUMB MECII
LICENSED CONTRA fOR'S DECLARATION APPLIANCES-RESIDENTIAL
p fyz I herebyaffirm that tum licensed underpmvisiocrof Chapter9(commencingwith LOB DESCRIPTIO
uFi 00[ Section]000)ol'Division 3 ofthe Businesinnd Prolesxions Gavle,and my license is in PANELS
=6E full fmueund effcn /�// ` '�n UPT02W AMPS
fF..Z, License Class�Lic.M 666-22 \
y6so Data Com 10m 201-1000 AMPS
ZOo^ ARCHITECTS UECGA'T
RION OVER INS)AMPS SQ.FT.FLOOR AREA E/SQ.IT.
OZ_.qqqq I understand my Plansshall be usedaspublic records. „
F='y SIGNS ELECTRICALCa Licensee Profeszionel
° u OWNER-BUILDER DEiCIARA'1']ON SPECIAL.QIRGDI'f/MISGM .
0, I hereby uffrm chat I em escrom from the Comremors License Law for the
W�Oy following reason.(Section 7031.5,Business and Professions Code:Any cityor county 'TEMP.METHR OR POLE INST.
m which requires o permit no construe'.altar,improve,demolish,of repair may ctrucmre -
;!(Y� prior m its issuance.eIxorequi.sthcappf,xmI.,such pound,to f le a signed stamnem POWER DEVICES
'a¢O that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
off 9(commencing with Section 7(1(101 of Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
W_rn
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIX'NRFS
F. G Section 7031.5 by anyupplicma for a permitsubjects the upplicem me ewilpanalty of
c not unnrc than five hunAred Antlers(SSW). NEWRESIDENTIALELECTR _SQ.FT. STORIES ITP-CONSTRUCTION
04 ❑ I,uusowneroFlheproperry,ormyemployeeswidhwagesm@cirsnlecompensmimt,
will do the work,and thesdmedure is not intcadedoroffered forsale(Sce.7f44,Business
and Professions Gale:The Contractors License Law does om apply to an owner of
prnpeny who builds nr improves Nercnn,end whmlocx such work himsclfor through his
wnemployees,providedthatsuch improvementsumnodimmn&edoroffemdformle.If. I DEC.GROUP RE'S.UNITS
however,the Noldingor improvement is sold withinoncfearofcnmpletion,the..,,. 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
n.).
❑ I,as owner of the Property,am exclusively contracting with licensed contractor m QTY. PLUMBING PERMIT FEF, fLOODZONE APN
Propvi
\\ cacenatmet the Pmjea(Sec.7444,Business and Professions Code:)The Contractors
mse
PERMIT 1SSUAN
Lil.0wdoes n INPly monowncrof Empeny whobuildscrinprovex themon,und
whoarntruca for such projects with u conractor(s)licensed porsuannnthe Contractors ALTER- N&VP.Nf-WATER(EA)License Law. FEESUMMARY
`❑ 1 am exempt under Sce. B&P C for this reasonU'1'SIDI; F E s.
ACK FLOW PROTECT.DEVICE SANITARY YN
Owner Da¢ DRAINS-BOOR,ROGF,AREA,COND. RECEIPT is
WOR KMAN COMPENSATION DECLARATION SCHOOLTAX - Y N
❑ Iherebyamtm dhoti havcaanificam of conxnuoself-imure,or.cenifcam RECEIPT
Workers'Com FIXTURES-PER TRAP
pensarionler this permit. rlificdcopy thereof(See. Lab C.7w b PARK FEE Y N
rat all empinyee'n under this permit. GAS-EA.SYS 01UTI.ETS RECEIPT h
policy p BUILDING DIVISION WiES
CompanyGAS-EA.SY F 4(I ) PLANCHECK FEE
❑ CmiOel copy is hereby fumisheJ.
E3Cenified copy is filed with the city Inspection division. F N STRL WAPINTOEfIrAGRADING FEF.
CERTIFICATE OF EXEMPTION MOM WORKERS' G S T SOILS TEF.
COMPENSATION INSURANCE
('Ibis section need not be completed ifthe permit is for one hundred nothus(SIW MzW SA 1'A Y-STORM G.20OIT. ENERGY FEE
less.)
I cenifythat dmth,peRotrnence ofthe work for which this non is issued,Isha11 I, WATIt HEATER WNHbI I'/ELECT
not employ any person in any manner so uIn u IIRM1Vorkefs' PAID
O z Compensation Luv s 'oro - T WATER SYSTEMfERIYsTING F Date Receipt M
Applicata
z 0— NOTICE TO APPLICANT.If,aOermaking tut' Certificate of Exemption,you should NEW RESIDEN'I'JAI.R. S TOTAL:
r � ca
beme suhjann the Work<rs Compcn atio powiumns.fthe Lehr Code.you most
F^ > fonhwiih comply with such pmvisionso sµrmItahulI be deemed revoked. BUILDING FEE
a �
W Q -
CONSTRUCTION LENDING AGENCY EISMIC F
i�"1. Z I hereby affirm that hem is o construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.CJ ELECTRIC FEE
Lender's Name .1 Apaiiiiiii
F^ Lender's AddressQTY. MECHANICAL I'LRMI'P FEE PLUMElING FEE
U 1 certify that I have read Nis application and state that the above information is
D"I carred.Imgree to comply with all city and county ordimmuca and state lows relating to PERMIT ISSUANCE MECHANICAL FEE
ybuildingconsuuction.and hereby 0uthmixempremomborsofdhis city m emerupon the CONS1RUCfION'fAX
U Z above-mentioned
progeny for Inspection purposes. ALTER OR ADD TO MECII.
(We)agree m save,indemnify..it keep harmless the City of Cupeninn against _
hithilities.pol9nents.cona and expenseswhich may in any waynceom against said City AIR I IANDLING UNIT(TO M."CFM)
inconsequence of this P=rmit.
/ AIR HANDLING UNIT(OVER 10,00f)CFM)I
Sign to.of Applicad Cannan, Date EiXHAUSTHOOD(W/DUCD PAID
HAZAantorRDOUS building
occALSDISCLOSURE
HEATING UNIT'D'O 100,100 BTU) Dam -
Will by applicant enfuture building ca.Cap store or andthandle hvurdous it Smell,
as defined by the Cupcnino Municipal Cale.Chapter 9.12,and the Hcnith and Sufcty HEATING UNIT(OVER IW,1100 BTU) 1'
Coda Section 25532(0)? VENTILATION FAN(SINGLE RISI D)
❑Yen ❑No
Will the mpplicamorfuwre building occupant umcquipmemmDevices wbichemit WW
NOILER-COMP(3HPOR I , OIORD ISSUAN EDATE
hazardous air com for arms as defined by the Bay Amo Air Quality Management BOILFR-COMP(OVHR I0BBX)BTU)
District?
❑Y. 11 No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the havrdous materials requirements under Chapter 6.95 Of the - "JUL 1819,
California I Iculth&Safety Code,Sections 25505,25533 and 25534. 1 understood that
if the hit ding does nm currently have a board,that ithmy responsibilitym notify the L
occupant of the requirements which must be met prim to issuance o1'a Certificate of ,CITY f a UI `H
Occupoocy. FF
- CITY 1 V
Owner or author!zed agent Dam TOTAL: ISSUED BY:
OFFICE