28086 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIJILL G./IN i-ELECI'R[CAL PERMITNO. 28086
� Q O H O
APPLICATION/PERMIT PLUMBIN -MECHANICAL G o
BUILDING DIVISION BUILDING PROJF.CIIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMHTAI.DATE
UNIT# LOT
OW`NjIJ,AiSS,,N`A`MIi: PHONE: INTaRACfOR'S NA(/�1�E�: ry/.- /� L �p�Fp� �O 1
n s'NN L-L, •—p�FCL= e— 5 G WIU QOII�S IL' k�F NAC CONTROL#
ARCHITEC A NGINEBR: LIC NO: ADDRESS: s-y, ❑
4-13 �SP-aA Sou CtazA
CONI'ACI': PHONE: QTY ELECTRIC PERMIT FEE NU ILDING PERMIT INFO
BLDG PLUMB MliCll
PERMIT ISSUANCE / ❑ 0
LICENSED ami CONTRACTOR'SDECIARATIl1N APPLIANCES-RF,SIIIENT'IAh �Ipy DESCRIPTION
OCZ ILcabyidErLICENSE licensed uACTORvisDECLARAI IO (commencing with �A}/\
¢001� Section 90flX0 of Division 3 crime Bminessand Popfc,siors C.jke.mdmy license is In PANELS
IVU full forecand effal.13 6 �� o UPT0200AMPS
"<c. Datenu Class Conn S
ti Dy Dara ConhazD 201-I01p AMPS SQ.IT.FLOOR AREA $?SQ.F-1'.
Z�NZ ARCHITECTS DECLARATION OVER 1000 AMPS
0 Z_- 1 understand my plans shall o used as public records.
'f,ret F; SIGNS ELECTRICAL
Q Y Licensed Professional
�yei< OWNER-BUILDER DECLARATION SPECIAL CIRCUYDMISC.
dOaU 1 hereby affirm that I on exempt firm the Contractor's License law for the
Way following reason.(Section]031.5,Business and Professions Cole:Any city or county TEMP.METER OR PULE INST.
F 4O'' which ommo,'a p.it m consumer,after,improve,demolish,or repair any compare
5,Y� prior to its issuance,also requires the applicant for such promitto file a signed statement POWER DEVICES
than he is licensed psm,tint ax the provisions ofthe Cmineelors License Law(Chapter SWIMMING POOL ELECTRIC 9(commercing with Section 900(I)of Division 3 of the Business anti Professions Code) VALUATION
❑y mdao he is exempt therefrom and Ne Ined,for Ne alleged exemption.Any violationo[
LZQ yxny app icon pe object, pp icon pens yo OUTLETS-SWRCIIIiS-FI%TURKS
Y ran ran Yth1Sh cion .it suM1 u thou l nn acivil It f
nrn more than Elm hundred dollars($500).
NEW RESIDHN ]Al.IA
'I'IAI ,IiCIR S .FT.
p ❑ I,mnwnenJtheproperty,ormyemploYees with wages as lhelrxnuromixnsudoq Q S'IYlN11iS TYPE GDN$TRDCTIGN
� m
a will dothe work,,and
e,Thp turcisnot intended Lavr ed[msale
pply at an maniocs i
unJ Pndesxion,.Cade:The Convenor's License Law does Hou apply at an owner of
foolery who buildsor improves thereon,andwhodnex such work himselforthroughhis
mam cmployees,Fmvidedthem ownimprovcmrnlsarcoal imeadmiromfcred I..the.If, OCC GROUP RIS.UNITS
however.the buildinger improvement is sold within one yerrofcompledon,Iheowaer- 0
builder will have the burden of proving that he did not build or improve for purpose of
sslc'k QTY PLUMBING PERMIT FEE
EII,asowneroflhepmpeny,amexclusivelycoanactingwiNlicenudcrnv ionto FLOOD ZONE APN
connmet the project(Sm.701 Business and Professions Calc:)
2-\
Liccntt lawdasnot aptlymanownetofpropcnywho buildsoimpro nd ISSUANCE
who contracts forsuch posersathacoalmerr(s)Iicensedpurso.-P- tor, ALTER-DRAIN&VIfVP-WATERERLicense Low, 1 ) FEESUMMARY
❑ 1umcuminunderSec. B BACK FLOW PROTECT.DEVICE SANITARY Ol1TYDE FEES N
• Owner D0' a DRAINS NOR,ROOF,AREA.COND. RECf:IPT#
WORKMAN COMPENSAT'IOND ION SCII001.'1'AX Y
ad
❑ Thereby xlOnn lhalhave acerificam rl consent sdfn rifnte FIXTURES-I'f: TRAP RECLIPI'p
Workers'Compen.sution Insurance arveenificd copy# c "(Sea r 8M.Lab CJw eh PARK FEE Y N
Covers all nnpyly 4 W l I. GAS-FA.SYSTE -1 INC.4 OUTLETS RECEIPT#
Polity#M `\is prpii�[Y � BUILDING DIVISION FSF_S
Company 117-1c)111 / GAS-EA,SYSTEM VGR 4(FA) PIANCHECK FEE
Cerifed copy is hereby fumis e .
Cenified copy is fled with Nc city inspectlun division. GREASFJINOUSTRL STE INTERCEPTOR GRADING FEE
FR
CERTIFICATE OF EXEMPTION OM WORKERS' GREASETRAP \ SOILS hili
COMPENSATION INSURANCE
This rasion tad nothcmmpleted if Ne permit is Forane hundred Ml (SIN) SEWER-S N ?ORM,I:A.200F1'. ENERGY ME
or 1,,.)f 1¢rify that in the performance of Ne work for which Nis permit is issu ,INall WAAR W/VENT '.[CTR
not employ any lerwn in any manner so as to become subject to the v kers' s PAID
Crn,scomionlAveaf Cxlifitall Dan \Y YSTFABTBCA NO Date Raei"If
OZ Applicant
O NOTICE TO APPLICANT:IL after musing this Certificate of Exemption,youmed WRESIDENTIAL LMB. SQ.FT. TOT L:
F^ � become subject tothe Worker's Compensation provisions of the Labor Cole.you mus
BUILDING FEE
forhwllb comply with such provisams of this .it shall lmcdeemed resulted.
CLl F
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby al'finn that there is a construction lending agency for the performance of V � TOTAL: IiLI:CTRIC IBiE
O Na work for which tltix pennh is isxuW(Sec.3097,Civ.CJ �
rr+ LendcLs Nun'c PLUMBING FEE
0 t^ Lenders Address QTY. MECHANICAL PERMIT FEE
C) 1 orm y Nat 1 have readmit application and state Lha the move information is MECHANICAL FEE
cmoct.lugmcmcomply wiuM1 ell city and county oMinances and smm laws relating uo PERMIT ISSUANCE
F' � buildingconnurvction.and hereby amNonce representatives ofthis city to eructation Ne CONSTRUCGONTAX
U Z abovcmentimed property for inspection purposes. ALTERORADDTOMECIL
(We)a m save,indemnify and keep M1amless the City of Cuperinr against
liabilities eau,ends and aslant vhich nomemanyway inemeagainstioid City AIR HANDLING UNIT(TO IR0NCFM)
incon eofuheg oiling of f it. s
AIR HANDLING UNIT(OVER 10.011)CFM)
Si naturcof Ap nt/Contracmr Dare EXHAUST HOLD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Rec'id,Y
Will the applicant or future building weruprat.aone or handle hazardous material HEATING UNIT(OVER 100,000 BI U) TOTAL:
as delined by the Cu,smino Municipal Code,Chapter 9,12,and the Health and Safety
Calc,Spann 25532D)1 VENT ILATION FAN(SINGLE RESID)
❑yes ❑ No
BOILER-COMPf311POR 100,11N)BIG) P9 Iysc4UANI UNQD�ATE
icn
Will lheupplm orlumre buildinguccupam nr
use equipment deviccx which emit p/
�reealloav air ceman omit,us deposed by the Bay Amro Air Quality Maongemcnt BOILER-COMP(OVER 100,000 BTU)
Dixlfinl MAY 12
❑Yes ❑No NEW RESIDENTIAL MHCII. SQ.IT. 70(15
1 have and the hazardous materials reymimmems mads,Chapter 6.95 of the IJJ JJ��
California Health&Safety Code.Sections 25505,25533 and 255X. I understand Nat CITY Uj-
if the building does not currently have a tenant,Nat it is my responsibility to notify the
occupant of the requirements which must M met prior to issuance of a Cerificam of
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE