28064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILISING-ELECTRICAL PERM IT NO. 1^8 O^4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. }V( lhJ
BUILDING PROJECT IDE:N'TINICA'I ION
BUILDING ADDRESS: a,/ SANITARY NO. APPLICAT10NSUBMITALDATE
Oe'1 I/lW UNITO LO'I'p � 5
HRS A i: PHONE CONTRACTOR'S NAME: LIC NO:
9616- NIC CONTROL#
RCHITECI'/IiNGINEER: LIC NO: P g: ❑
COM'ACT: PHONE:
/' QTY. EI :LYRIC PERMIT FEF. BUILDING PERMIT INFO
S 1 i 5e -- 1� BLDG ELECT P UMfl MF.CII
PERMIT ISSUANCE 0 0
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL J DESCR��
POOnwz Ih7")ereby of affirm that I
3 ofth Buinessad under roProfessions
Cole,and mmendng with
Y100 Sation]OW)nf Divixinn3 of the Business and Professions Code,and my license is in ppNE1S � 1 1
�' full f..mindeffwt. ///��ssss��g,,,........
g:Zm License Class Lic.p UP 90200 AMPS `
may Date Comb etar 201-["AMPS
Z O= ARCHITECT'S DECLARATION SQ.M.FLOOR AREA S/gQ.FT.
p Z_1] I understand my plans shall be used as public t«arts. OVER 1000 AMPS
r m kj W SIGNS ELECTRICAL
Licensed Pmfcsiomal
�yd'a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
q�SO a F 1 hereby am.that 1 um exempt from the Contractor's License Law fur the
I+E3�m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
k�• which requims a permit to construct.alter,improve,demolish,or repair any structure
prior to its Issuance.also requires the applicant for Such Permit 10 Elea signed statement POWER DEVICES
y(�0 p that he is licensed pursuant m the provisions of the Communes License Law(Chapter
aao�' 9(commencing with Section 7")ofDivision 3 Writhe Businessland Professions Code) SWIMMING POOL EIPCIRIC VALUATION
R ,-m
or man he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHPS-
�zQSection 7031.5 by a my applicant for a permit subjects the applicant a civil penalty of FIXTURES
cenm more than five hundred dollars(1500). NEW RESIDENTIAL ELECIR _SQ.PT.
❑ I,sowneroftbepropeit nrmycmpinyeeswith wegesavheiraolecomtiensaion, STORIES TYPECONSTRUCTION
y .e will do the wnrk.and the structure isaniinummil oroffered forale(Sce.7044,Business
and Professions Care:The Contrannrs License Law does not apply to an owner of
prnperry whobuilds or improves thereon,and whodoes such work himselforthrough his
ownemploys,provided that such impro.ementsam not intendadoroffered forage.If. OCC.GROUP RES.UNITS
ee
however,the buitdingor improvement is sold within oneyear ofcompletion,the owner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property.amesclusivelycomricting with beamed contractors m QTY. PLUMBING PERMIT FEE FLOODZONE APN
ousbact the project(Sec.7144,Business and Professions Code)The Comracmr's PERMIT ISSUANCE
License Inw d«s nm apply m un owner of property w ho bu Ids m improves lhcrcon,and
who contracts for such projects with amintractm(s)licensed pursuant to the Couracmrs ALTER (EA)
License Law. FEES SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.OB VICE SANITARY Y_F_S N
Owner Ume pRA1N5-F100RROOFAREAGONDRECI?IPl'M
, . , .
WOR KA kN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ l hereby affirm that Ioveacenificateofconsennaulfinsure,oracenifcateof FIXTURES-PI7R TRAP #--- RECEIPTY
Wmkers'Compenauionl sumnceoraceniriMcopythemof(Sa.39M,i bC.)wMch PARKFRF. Y N
cavenallemployeeru erihispermit GAS-1:A.SYSTEM-1 INC.40l1TLE1S RECF.IP`#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ CenifcJ copy is arab,fumishal.
101Cenifie i copy filed w116 the city inspia`n dIv ion. GREASrONDUSTRL WASTE?INTERCEPTOR GRADING FEE
CER IFIC LOFr(EM O ORKERS' GREASE TRAP SOILS FEE
P O RANCC
(Thisseeion a tiff the permit is Perone hundred of 100) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
roles'.
Ieenifytha nth,pe care ofth,w� farmi'RItltL tisf a dl WATER HEATER W/VENT/ELRCIR
net employ any perstm in an in nc to base 1 1r the .kers' PAID
Compensanionl ws ref Celi ia. Orae WATER SYSTEM/TREATING Date RecciptN
z Applicant NEW RESIDENTIAL PLMB. S .IT.
zO 0 A pflea•TO PLIC W:If,eOcr making this Cenificau of Exemption,, rugal Q TOTAL:
LI) Forum.subjec to the Wmkma Compensation provision,of the Labor C ,you must
C� > forthwith cam ly with such provisions or this permit shall be deems, evoked. BUILDING FEE
aQ CONSTRUCTION LENDING ADEN SEISMIC FEE
Vz 1 hereby ff thenhere is a conswetion Ithduergemy far the famfornonce of
O the work for w ich this permit is issued(Sec. ,Co.C.) �• ELECTRIC FEE
LendersPiamc ETI
T PLUMBING FF.E p 0-
U Lenderres
's Adds QTY. MECHANICAL PERMIT FEE
I emit,that 1 have read this application and state that the above information is
kkl curvet. l agree m comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL FEE
ybuilding construction,and hereby authorim represenlativesofthis city mermr upon Ne
U Z above-mentin red property for inspection purposes. ALTER OR ADD TO MECH, CONSTRUCTION TAX
&!9
harmless the City of Culici ire againstmayin anywayuccmeegx id City AIR HANDLING (TO
AIR HANDLING UNIT(OVER 10,01111 CPM)
Signature of Applicant/ 51memr //✓Nl Data EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEMING UNIT CFO EXLK0 BTU) Dam Raeipl p
Will the npplicnm or toric building ommi m store or handle barurdrm material
as defined by the Capella.Municipal Code,Chapter 9.12,endme l health and Safety I MATING ON['[(OVER 100,00(0)BTU) TOTAL:
Code,Sateen x)?
ElYYes ❑No
VENTILATION FAN(SINGLE RISID)
Yes
BOILER-COMP(3HP OR 100,0(10 BTU) Sl eNCE T
Will theapplicent or future building«cupam oneyuipmcnmrdeviceswhichemit s� B®
h.mntin s air enroll vents as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER'100,(M 0 BTU) - ��
Daniel? dJ
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. Cs' �QJO 7n
I have read the hrrardeus materials rcyuimmems under Chapter 6.95 of the
California Health&Safety Care,Sections 21505,25533 and 25534. 1 undersand that �.GF•L
if the building dors not curendy have.return.that it is my responsibility to notify the C
emotional of the mindom Its which must be met Prim to issuance of a Cer iftcate of
Occupancy. �.•}��It►/[��,
Owner or eothodzW agent Date TOTAL: ISSUED BY:
OFFICE