28277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL 28277 8^
BUILDING DIVISION BUIL ING PRWECT IDENTIFICA9'ION
BUILDING ADDRESS: ..1 Ile—
�/� / SANITARY NO. APPLICATION SUBMITTAL DATE
IIV Y�V(*" U I# LOT#
O NERS NAM 1 PHONE: CO ACT(1 IC NO: N/C CONTROL#
RCHI C /ENGINEER: [_Jl, LIC NO: ADDRESS. . ❑
oNTACT. puoNE. -1L.�.f(�, BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
1 ^Z I0e' BLDG ELECT P1.UM�B MECH
�s c- -1ISSUANCE. � � p(I' ❑
LICENSED COLD RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
mwz I herebyoffnnrhat l am licensedunder provisions of Chepeor 9 bermmencing with F
x100 Sw[ion]000)of Division 3 of the Business and Profresrons Code,and my Iwnse is in PANELS
fullforceand df 2
G mm Dwe", — Lia# D7�Z UP TO 200 AMPS
rFii 0. Uac Convector
I"'i-i 0 ARCHITECTS DECLARATION 201-1000 AMPS S FI'.FLOOR AREA $/SQ.FT.
OZ-O 1 understand my plans shall be used.,.line retards. OVER IOW AMPS Q'
r 4 HSIGNS ELECTRICAL
.4 Licensed Professional
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M[SC.
wOa1- 1 hereby affirm that I am exempt from the Convectors License Law fur the
3�a 611nwing reason(Section]031.S,Business and Professions Code:Any city or county TIME.METER OR POLE INST.
.] which requires a permit to consumer,alter,improve,demolish,or repair my structure
j'� priortoitsissuanre,also requlresme applicant forsuch pe.iuo fileaslgned statement POWER DEVICES
00 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
tar
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W...rn orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of Of1TLETS-SWITCHES-FIXTURES
[r 6 Section 9031.5 by any applicant for a permit subjects the applicant a civil penalty of
y^y not more than five hundred dollars Might.
m ElI.mownerofthepmperty,ormyemployeeswith wages animursolecompengatiNEW RESIDENTIAL ELECTR S .FT.
on, Q STORIES TYPE CONSTRUCTION
y will dome work,and the structure isnot intendedoreffated forsale(Sec.7W,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whobuildsmimpmvesdareon,andwhodoesmi,h work himselforthrough his P
ow anoployees,providem
drhat such improveentsaronotimendedoroffned frrsale.If, OCC GROURES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sola).
❑ I,as oammofthepropeny,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Seo.7044,Business and RaGaslons Code:)The Contracts
License Lawdresnrtehidy toflummermincipery,whobuildsorimprovesthereon,and PERMIT ISSUANCE
whowaracts forsuch projects with a contractoHs)licensed pursuant to the Contrdcmrs ALTER FEE SUMMARY
Licame Law. WATER(EA)
❑ I am exempt under Site ,B&P C far this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date SANITARY RECEIPT#—N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND. SCHOOL TAX Y N
❑ Iherebyarfirm lhmlheveacenificua of cnnsenno eel6insum,nrewnificas of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a certified copy thereof(See.3800,Lab C.)which PARK FEE Y -
N-movers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifrd copy is hereby furnished.
❑ Certifed copy is filed with the city inspection division. GREASE/INDUSTRLWASTEINTERCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need mobe completed Enna permit is for one hundred dollarsHigh) SEWER-SANITARY-STORM EA.20IFT. ENERGY FEE
orless.)
I cenify but in the performancemf the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ my person in any manager so as to become subject to the Workers PAID
z Compensation Lx
awnf Cellfrmis. Date WATER SYSTEM/TREATING Dade, Receipt It
Applicant
z��7--1 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-� (O become subject the Workers Compensation Provisions of the Labor Code,you must
••"�--�� forthwith comply with such provisions or this permit shall be deemed revokeJ. _ ...... .......: .�' " BUILDING FEE
W [� CONSTRUCTION LENDING'AGENCY t SEISMIC FEE
•^a z I herebyaffrm that there is u conswetier[bring aggency for the performance of T ELECTRIC FEE
U O w
the ork for which this permit is issued(Sec.3055],Civ.,C) 1
"'"
Gtr Lender's Name ' _ r PLUMBING FEE'
Lender's Address T' QTY. "'M��f CAL PERMIT FEE
O U I cenify that I have rend this application and state chat N v, formed is
a coma.(agree to comply with all city and county rMinancesais
av relaingm PERMIT 6 MECHANICAL FEE
rA building commuctlon,and hereby authorise represenntives afdhisTdymenterupomh .9 CONSTRUCTION TAX
U K above-memirnad property for inspection purposes., yy--s�s�Y'-T❑❑ R MEC t -
(We)agree ro save,Indemnify and keep heradags t'e City of yyp TET -
llabiliries,judgmenw,costs andexpenass which maany crueagainstsaid City AIR HANDLING UNIT IQ00 ' FM)
sequen eof granting of this a hr
mo
RHANOLJNGIUNIT(OVER IO,WOCFM)
Slinamre of AppbcanVCanmaor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle harardous material
as defir xt by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T L:
Code,Section 25532(e)]
11 Yes 12 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will third Iicmtorfu as building pen q purer BOILER COMP(3HP OR IW,Wf BTU) P A
pp gotta fusee ui mrdeviceswhichemi[
hazardous air contaminants as defined by the Buy Area Air Quality Management
istrict^ BOILER-COMP(OVER 100,000 BTU)
❑Yes 11 No NEW RESIDENTIAL MECH, SQ.FT. JUL �1 ����
I haveVI read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if rhe building does not cumn0y haven morm,Ibat it is my responsibility mortify the ���Y UI- aur
farmland of the requlremcros which inn d be met private issuance of a Cenifwte of '`�
Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE