28121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING ELETRI AL PERMIT NO, p
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAL
20121
BUILDING PROJECT IDEN'T'IFICATION
BUILDINOIRRRA�1 IINITM LOTN SANITARY NO. APPLICATION DATE
OW Nf• .7 PHONE: RA 1. 'SN E: LIC NO: N/C CONTROL# SS
• ARCIiiTI?CI'/IiNGINGER: i. LIC NO: DNESS:
CONTACT: PHONE_
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF:CtI
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION 001ZAPPLIANCES-RESIDENTIAL JOB DESCRIPTION_-
F100 Iherehy dfirmision 3 ofin,sed Business
and refesofCh Code,and
with , Y `nWQV.'J�ps'O�NA`
�i100 Section 71X10)of Division3ofrhe Business and Prokuions Code,and mylicenu is in ppNF:IS \ �
q'V E fall foes and effect. '
tZZ,, License Cls 13 Lic.N UPT02MAMPS
FAN Date Contractor 201.lots)AMPS
zOy� ARCI IITECTS DECLARATION OVER 1000 AMPS
SQ.FF.17.00R AREA S/SQ.PI'.
O z- 1 undaniyrW p Flaw shall be used ex public records.
P,Ag J/c1 , SIGNS ELECTRICAL
Ltc<ns�c1"rofessst,
qOWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC.
X00.10., 1 hereby affirm that[am exempt from the Contractor's License Law for the
W 3Ote following reason.(Sed inn 703 1.5,Business and Professions Gale:Any city or county TEMP,MLIFER OR POLE INST.
1--2:on which requires a permit to construct.aline improve,demolish,or repair any swcmrc
}� prior,.its insurance,also requites the applicam for such permiuo file.signed statement POWERDEVICES
Q Oz that he is licensed pursuant to the provisions of the Carnmeni License Law(Chapter
0. �oLL 9(commencing with Section 7")of Division of the Business and Professions Cole) SWIMMING POOL ELECTRIC VALUATION
yYj_,y or that he is exemprtherefmm and the buffs for the alleged exemption.Any violation of
L. a Section 91131.5 by any appllcum l'oru permit suhjcds the apPlicannoucivil penolty of 011'1'I.hrs-SWI'ICIIES-FIXTURES
u❑Sp 0 not more than five hontlreJ
dollars($500).
13NGW RPSIDENTIALI3LECIR _SQ.FT.I,mownttofthe Mao ay,ormyemployceswithwage,mtheinolecompemation, STORIES TYPECONSTRUC'FION
y3_ will do the work,andthe structure isnot intended aroRerd fnraale(Sm.9044,Business
and Profess ns Code:The Commerce.License Law does t apply m o
on owner of
property who nobuilds or improves thereon,and who does such work normal for through his
own emmloyees,nookled ihatxuch impmvememsaren.,marrdel orofficedformle,If, OCC.GROUP RES.ONT'1'S
however,the building or Imerovement is sold within one yearmfcomplelion,the owner. A
builder will have the burden of proving that he did not build or improve for purpose of
ale).
❑ I,as awnerofthe portion,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct
the project(See 7044,Business and Professions Cole)The Connector's
L
kens.Urwdoes untimely m un OwnerOfprupany whobuilds.,improve,thcremt,and PERMIT ISSUANCE
whocon(mns for such projects with acommmorod licensed puromen to the Commcier'e
License Law. ALTER-DRAIN&VENT-WATER(PA) F13E SUMMARY
❑ 1 um exempt undtt Sec. ,B&P C for Nie rcmon BACK ROW PROTECT.DEVICE SANITARY OUTSIDEY N
Owner Date RECEIPT#
WORKMAN COMPENSA9'ION DECLARATION DRAINS-FLOOR,ROOP,AREA,COND. SCHOOLTAX Y N
• EI,l hereby affirm that l have a cenificam of consent o allf.icami,or.coni ficam of I7XTURES-PER TRA(' RECEII'fp
Warkcrs'Compensemion Insurance ear.ceniliW copy thereof(Sec.38W,Lob C.)which PARK FIDE YN
RECEIPT 0
covers.11 Policy p cmpiny>`s uundera rj/p q GAS-PA.SYSTEM-1 INC.40UTLLTg BUILDING DIVISION FEES
Company ' •ZJ/ / / GAS-P.A.SYSTEM-OVER 4(EAT PIANCHECK FEE
[?�CcrtifiM copy is hereby furnished.
❑ Certified copy is fled with the city ie,pectimn division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section new not be completed ifthe Permit is for one hundred dollars($100p SEWER-SANITARY-STORM EA.200FT. ENERGY HE
or less.)
I ccddy(lint in the Perfnmwnce of the work for which this permit is Issued,)shall WA-1 HR I(EATER W/VENT/ELECI'R
not employ any person in any manner so as m become subject,.the Wake. PAID
Z Compe.mtionlwwsof California. Data WATER SYSTEM/BIIATING pore RmciP1N
O O Applicant
z7 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V.
Pbecome suhject to the Worker's Compensation previsions often Labor Code,you must
.
moi , forthwith cmmnply with such provisions or this permit shell ba deemed revoked. BUILDING PER aha
(] CONSTRUCTION LENDING AGENCY SEI SMIC FEE
I heathy affirm that there is a construction leading agency for the performance of :
V O the work for which this permit is issued(Sm.3097,Civ.C.) TOTALELECfItIC FEE
Lender`s Name
O U Latices Address QTY. MECHANICAL PERMIT ITE PLUMBING FEE
1 certify that I have read this application and state that the above information is
}' correct.Ira to comply with all cit and ordinances and state laws relating m PERMI'T.15SUA Td I'! MECHANICAL PEE
agree PYhe city county g
h-' Z abravengcomtructionTert horbypectioiu rcpracnutivesof this city menterupon the '"' CONSTRUCTION TAX
V z above-memiened pmpeny for inspection purposes. �agains+s ALTCR OR ADD TO F,CIi� --
(We)agree to save,indemnify and keep harmless the CitX of{Gupeilnb against
Ilabilhies,jndgmenb,costs unA expenses which n..yr oy"W)'mciueug.hxc sold City R DLI (TOIQrp0CFM)
ftl gmming of this memmit. •,/k ,AIRHANDLINGU OVER10,IXIOCPM)
nature of App i<anUC�icior me rtyl EXT' U.tpf H` ( >UCT)
PAID
HAZARDOUS MATERIALS OISCLO URE( 5, .� HE ' 1 NMT O N1,0(N] ) Do,. Receipt#
Will theupplicam or futurcouldingeempmn stole ear bt
doses materia
as definuf by the Cupertino Municipal Cade,Chapter 9.12,0uhh agdSafety 'UNI'I'(OVEI21 W,p0pB TOTAL
Cale,Section 25512(a)1 D VP.NfILAT10N FAN-(9/m1GLE RESID)
ISSMAE
Will the upplicamnr futumbuildingmempuntuseIA",
evices yhia � 'bQ�ILER-GOMP(3HP OR 100,00fI BTU) Y 6J
District? air mmaminants as Aefnw by the Bay M�.gemem �� NA
Y23
❑Yes d-N. � BOILER-COMP(OVIiR IW,WO BTU) ��fj
NEW RESIDENTIAL.MECH. SQ.FT. P7J 19QC
I have read the hazardous materials requirements under Chapter 6.95 of the Cl1 r v4Y
Cnlifomia I Ieablm&Safety CMe,Sections 25505,25533 and 25574. 1 understand that Ur (,UrtNlINO
occupant
Binge requirements
which
le,met prior issuance
of
toomify the
Occupam yl the reyuiremems which must he mc(prior to issuance of a Certificate of
Occupancy.
Owner or enhanced agent Data TOTAL: ISSUED BY:
OFFICE
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