28004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO III ILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 28004
BUILDING DIVISION BUILDING PROJECT IDENTIPICA"PION
BUILDING ADORES .�•L�r. 1`�.�,1 y/���/{�y� ��/�/ SANITARY NO. APPLICATION
SSUBMITIAL DATE
l`Y' `�N/\✓ UNIT# LOT#
OWNIi MF.: �J PHONE: ACfOR'S NAME: LIC NO 1. r'
(f/1/ Sti 1 Q2/, Z` H8 Z M1 e 6VOU I NIC CONTROL#
ARCHI'IECT/ENGINEER: LIC NO: ADDRESS: C.,j
❑
u
CONTACT: PHONE:
" QT'Y. ELECTRIC PERMITFEF, BUILDING PERMITINFO
P BLDG arm PLUME MECH
PERMIT ISSUANC17
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IDH DESCRIPf N
Oy/ I hereby affirm than l um licensed under provisions of Chapter9(commencing with
W00 Section l(XX))of Division3 of the Business and Professions Cod,and my license is in PANELS �I"�/)
full lures and lY1V�-
F L W License Class �`3 G Lic.N G �(/V40/ UP TO 2M AMPS -
yjy Date Contractor 201-1000 AMPS S FT.FLOOR AREA E/SQ.FT.
JlO v%� ARCIIITFCTS DECLARATION OVER Ralph AMPS Q
OZ�❑ I understand my plans shall be used.,publicrecn.Js.
SIGNS ELECTRICAL.
QY$j Licensed Pome,sion.l
K
o'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaU 1 hereby affirm that I am exempt from the Convectors License law for the
w3LLy which following
eiresa eorai it)co3L5,Buaincav and Professions Code:Any city.,county TEMP.METER OR POLE INST.
ANO; whish requ'ne,a pennil m construct,alter,improve,denvtli,M1,or repair any stmeturt
�'I�Y� prior in its issuance.also requires the applicant for such permit to file a signed statement POWER DEVICES
¢0 that he islicensed pursuant to the provisions of the Caroni License Law(Chapter SWIMMING POOL ELECTRIC p•Xo� (comm000
9encing with Section 7")of Division 3 of the Business and Professions Cade) VALUATION
W man .,that he is cscmpuhcmfrom and the basis for the alleged exemption.Any violation of OUTLETS
al4 Section 9031.5 by any applicant for a permit subjects the applicant a civil penalty of
p areae Nan rofthe rr)Jnyllarmyomp. NEW RISIDENfIALELECTR _SQ,FT. STORIES TYPHCONSTRUCTION
KHp wi othe wnk andilinspcny,as notimoyeeswoffoomsa.theiSm.compensation,
i3°O will doshewores Coh: rte Comisnoes License
Law dots not aWly t oan Business
and Pmfcssions Cale:The Conuxmra License law docs not apply to an owner of
property who builds or improves themon,and who does such work himself er through his
employees,provided that such improverecosare notinundedaoffced forsal,If, OCC.GROUP RES.UNITS
however,me building or improvement is sold within one year ofeampletinn,the owner.
TOTAL:
builder will have the burden of proving that he did sol build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as ownerofthe property,son exclusively contracting with licensed contractors to
construct the project(Sec.9044,Business and Pcnf,vions Code:)The Contractor's
Licentt Lnwdoesnm applymov ownenaf p,.,nywh,,b.ild,orimpmvexiberton,and PERMIT ISSUANCE
who contracts for such pmjecrs with arommemr(s)licensed pursuant to the Contractor's se law.
License
pLTIiR-DRAIN&VPM-WATIiH(EA) FEE SUMMARY
❑ l amesempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE FEES
N
Owner Date DRAINS-FLOORNOOPAREACOND. RECEIPTp
, . .
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y N
❑ Thereby affirm thatlheveacen%freatc ofconum malt-insure.mecenifcau of RECEIPTa
a FIXTURES-PER TRAP
Workers CmployeeanlmumnarracenifiW copy lhemof(Sec.JSOO.IabCJwhich PARK Y N
covers all emploYec's under this permit. GAS-[A.SYSTEM-I INC.4 OUTLETS RECEIPT'a
Policy p BUILDING DIVISION PEES
Company GAS-IiA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ CcnifW ropy is hereby furnished.
❑ Cmirede.m'i,flWwi the city" no.division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE E ION FIR ORIE / GRPASETRAP SOILS stili
C TIONINSUR N
('this acctri ifthe permit hundmildellurs(SI00) SEWER-SANITARY-STORM HA.200 p. ENERGY FEE
err lev.c s7
I erify cperfo�,n work for which this permit is iasucd,lshall WATER HEATER W/VFM/GLECTR
not employ any oa m y manner so a to become subject to the Worked PAID
Compensation Ln fCuliomin. Date WATIiR SYSTEM/TRPATING Date Receipt
Q z Applicant
z � NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should NEW RESIDENTIALPLh1B. SQ FT. TOTAL:
y become subject to the Workers Compensation provisions of the Labor Cal,you mail
P:
> fonhwinh comply with such provisions or this permit shall bo deemed revoked. BUILDING FEE
D. CONSTRUCUON LENDING AGENCY SEISMIC FEE
I family affirm Thal there is a ennnruction fic ding.gcncy for the perfntmance of
U z 'A ELECTRIC ITE
O the work for which This pcmlil is issued(Sec.3091.Civ.C.)
Lender.Name PLUMBING FEE
u" F Iendcr's Address QTY. MECHANICAL PERMIT FEE �w
V I certify that I have rend this application and state that Ne above information is MECHANICAL FEE
.>'s CL1 comet. l agree a comply with all city and county ordinances and state laws relating to P17RMI'I'ISSUANCE
F^ h buildingasnstruchim,and hereby malaria rcpmunmtivesofthiscbywemcr upon the CONSTRUCTION TAX
V z above-mcminned property for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep harmless the City of Cupertino against
I iabi lines.judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
lac on ace of the granting of,h pennil.
AIR IIANDUNC UNIT(OVER IU.UIX)CFM)
100 4
Sig rtof Applicant/ omracto Dau EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dau Receipt p
WdI be upplicam or future building occupant ume or handle h oradmis minimal IIEATING UNIT(OVER 1(ah"BTU) T
as defined by the Cupertino Municipal Cod,Chapter 9.12.and Ne Health and Safety
CWe,Section 255321e)? VENTILATION FAN(SINGLE RESID)
❑1'es ❑No
f,- ISSUANCE 13ATE
Will the applicant orlature •D
bnilJin eco mNevicetwM1leM1 emit BOIhER-COMP(311P OR IM."BTU) V
�/
• hnmrdnus air contaminants as defined by the Buy Area Air Quality Manegemenl gpe.L'R-COMP(OVER IIXl.gs(1 g'1'U) � � � '1n
District? IJ
El Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
9,5
1 have road the haemwas material,r mmmems ander Chapter 6.95 of the h L14,4-lyfgy0
California lIwIN k Safety Code Sections 25505,25533 and 25534. 1 code...and that
if the building does not currently have a mason,that it is my responsibility to notify the
occupant of the requimmems which most be met mina,issuance of.Certificate of
Occupancy.
Owner n,nnthmiral ttgcat Date TOTAL: ISSUED BY:
OFFICE
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