28241APPLICANT TO FILL IN INFORMATION WITHIN wen I lupe _ Hee mnl I enlHt ooar n.rr xe
BUILDING - ELECTRICAL
ITYOFCUPEAPPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISSIOIO NO N -
PEaMITNO.
BUILDING PROJECT IDENTIFICATION
28241
BUILDING ADDRESS:
e
UNIT# LOT is
O RgN ME _ `/ p PHONE: CONTRACTOR'S NAME: LIC NO:
-7G 0
SANITARY NO.
APPLICATION SUBMITTAL DATE
N/C
El
CONTROL #
-7Z7/14i
ARCHITECT/ENGINE•ER: OLIC NO:
—��
ADDRESS:
CONTACT: PHONE:
QTY
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERMIT ISSUANCE
BLDG i ELECT PLUMB MOH
1L-rJi/
LICENSED CONT CTOR'S DECLARATION
y Iherebynffirmthal l amlicensedunderprovisions ofCxii(commencing with
Section ]000) of Division 3 of the Business and Professions Code, and no, license is in
full force and affair
J Liccn tae Lio.#
n Due ConnectorTS
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 200 AMPS
AMPS
Zj ARCHITECTS DF. ARATION
1 understand my plans shall he used as public recoMs.
SQ. FT. FLOO AREA
$/S PT.
Q'
AMPS
CTRICAL
Lmensed ProRaetonal
4
OWNER -BUILDER DECLARATION
1 hereby affrrn that I am exempt from the Commode. License Law for the
n following mason, (Section ]031.5, Business and Professions Code: Any city or county
which requires a permit m consumer, Must, improve, demolish, or repair any structure
Prior to its issuance, also requires the applicant for such Permit file a signed statement
rthat he is licensed pursuant to the provisions of the Commences License Law (Chapter
L 9(commencing with Section TIDO) of Division 3 of the Business and Professions Code)
.1 but he is exempt merefmm and the basis for thealleged exemption. Anyvimitioa of
by any applicant fora permit subjects theapplicanuoa civil enalty of
not mare than five hundred dollars (5500).
o.❑ I,asownmoflhe n
prop¢lum is not forihe(Sce. compensiioq
will dothework, and the he tul isnotimendedorofferedforsale(Sec.]044,B owner of and Professions Code: The Contractors License Law does oat avply lf an owner mf
propmywho builds orimp rovesthereon, nndwhn doessuch work himeelforthrough his
ownemployecs,provided Nntsuch improvememsarenorimendedorofferedforsale. If,
however, the building orimprovement is sold within one yearofcomphoom the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
IRCUIT/MISC.
TER OR POLE INST.
MDEVICES
VICES
G POOL ELECTRIC
VALUATION
�a�Section7031.5
-SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR —SQA
S'T'ORIES
TYPE CONSTRUCTION
OCC. GROUP
RFS. UNITS
-
TOTAL:
QTYPLUMBING PERMIT FEE
PERMITISSUANCF
ALTERR- DRAIN& T -WA RIBA)
BACK FLOW OTECT. DEVICE
❑ 1, as ownerofthepeoperty, am exclusively contracting with licensed contractors In
consumer the project (Sec. 7144, Business and Professions Code:) The Contractor,
License Lawdoes amapply to anowmerofpmpen, who builds comprovestherned. and
whocontracts fourteen projects with a coureemf(s) licensed pursuant to the Contractor's
License Law.
1 em exempt under Sec.
❑ , B & P C for this reason
FLOOD ZONE APN
PEE SUMMARY
OUTS 10 E FEES
OwnerSANITARY
Detu
Y N
WORKMAN COMPENSATION DECLARATION
❑ Iherebyaffirmen Instance orncernicof consentmsel(See. rgm uani.) which
Wvers al Cmployees nderthincermi cenifed copy thereof (Sec. 3800, Lab CJ which
covers all employee's under this Permit.
Policy N
DRAI - FLOOR, ROOF, AREA, CO
RECEIPT#
SCHOOLTAX Y_ry
RECEIPT#
TURES - PER TRAP
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
Company
GAS - EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
❑ Certified copy is hereby famished
PLANCHFCK FEE
ElCenified copy is filed with the city inspection division.
GREASE/INDUSTR WASTE IN'ILRCEPTO
GRADING FEE
CERTIFICATE OF EXEMPHON FROM WORKERS'
COMPENSATION INSURANCE
G ASET P
SOILS FEE
(This section need not be completed if the permit is for handre o11ars4I00)
or lass.)
SEWER -S I -STOR
ENEROY FEE
I certify that in the performance ofthe work for which this permit' (sued, I shall
not employ any person In any manner so as to become subjat t the W rkars'
Cpo iximeation Laws of Califoodo Date
Applicant
A TER WNENT
PAID
Date Receipt #
AMR SYSTEM NO
NOTICE TO APPLICANT: If, after making this Certificme of F.xempB ,you should
become subject to the Worker's Compensation provisions of the Lal m C e, you must
forthwith comPly with such provisions or this permit shall he deemed rev ked.
NE D99TIAL LMB. SQ. FT.
TOTAL:
BUILDING FEF
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the pert cami
the work for which this .jt),s lssioaddSoc. 30V7, Civ. C.)
Lenders Name
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that I have read this epplierion and eta¢ thm the above Inform.' n is
PERMITISSUANCE
MECHANICAL FEE
correct. l agree to comply with all city and county mrdinencn end amu laws relatin
buildingeonstruction, and hereby amhnrin represerni ivesof this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep hornless the City of Common against
liabilities,judgments, costs and expenses which may in any way accrue against said City
nseyuence oft giant in of this permit.
ALTER OR ADD TO MECH.
AIR HANDLING I/NIT(TO 10,00) CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,000 CFM)
Sign remf Applicam/C rotDate
EXHAUSTH00D(W/DUCn
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIAL DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materiel
Dare Receips#
L
as defined rhe Cupertino Municipal Code, Chapter 9.12, and the Hcaltli and Safety
Cade, Section 25532(¢)7
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESIO)
❑Yes ❑ No
J
Will tan, co tionimintsa building occupby 'he
hazardous air conmminwts as defined by the Bny A. Air Quality Management
Quality Manage ant
District?District?
BOILER - COMP (THP OR 100,041 BTU)
ISSUANCE DATE
/�
BOILER -COMP (OVER 100,000 BTU
- )
❑ Yes ❑ No
A
NEW RESIDENTIAL MECH. SQ. FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not curently have a tenant, that it is my responsibility to notify the
occupmnts
ant of the requireewhich must h met prior to issuance of a Ccnifcate of
Occupancy.
: 61995
�/�
BY:
Owner or nmhonzed agent Dam
TOTAL: ISSUED
uFRCE