28112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
8 CITYOFCUPERTINOBUILIIING; ELECT RICA[ PERMIT NO,
l/ BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28112
BUILDING PROJECT IDEN'OF'ICATION
DINGADDRES SANITARY No, APPIACKLO.NN SUBBMII"ITN,DATE:
91I3/ 4K l;//,a e'I_ UNIT# 1.
'RS NA E. IONS: CONS'RACIO NAME: LIC NO: —
MrA/ L N/C /CUN'IROLX
RCHITECT iNCINEER: /r IC NOA DRESS. ❑
CONTACT: PHONE: RUILDING PERMIT INFO
QTY. ELIiCTRIC PERMIT FEE
BLIIC- I" lEPLUMB MECII
PERMIT ISSUANCE 0 El
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RF.SIDIENTIAL $$LL���I��N
CKZ Ihereby affims that l am licensed under provisionsof Chapters(commencing with
�!00 8<mion]tW)of Division3of the Business and Professions Code,and my licenu is in PANEUS I ��+*J
CW full Gareand otleC. UP TO 2W)AMPS \/ 5
F Z m License Class Lic.X
y=y Date Contractor 201-]"AMPS
F- ' ARCHITECTS DECLARATION SQ.FT.FLUOR AREA $/SQ.FT.
70y— OVER IOW AMPS
I undersanad my plare,hell M used re Public records.
1-sal
SIGNS ELECTRICAL
Q Licensed Professional
eei OWNER-HUILDF.R DECLJG\T[ON SPECIAL CIR T/MISC.
KO c. 1 hereby affirm That I sm exempt from the Contractor's Liccnu Law for the
W3¢r~i, following reason(Section]03 L5.Business and Profusions Cute:Any city ar county —51`6i
R OR EINST.
�� wM1ich rcyuires v permit to ttmavucL otter,improve,demolish,or repair my strvaum
�wY� to its issuance.alsort thea licant fur such t sa.v PoWER DEVICES
pnar 4uires PP 1<nni
W tY Q that he is licensed pursuant to the prm:sians of the Contractor's License Law(CTapmr
(
1�'❑P 9 commcncin6with Semian 7")of Division Jofthe Easiness and Professions Code) g IMMING POOL ELECTRIC VALUATION
G
or that he i s exempt therefrom and the basis for the alleged exemption.Any violation of anOUTL. SWITCHES
Section
F-Z ]031.5 by any applicant for a pertad subjects the applicant to a civil penalty of
_ nof mare than five hundred dollars($500). 1-
�tm ❑ I,asowncrul tM1e pnapctly.onny mnplayenwiN wages as lheirsnlecnmPensatiaq NEW PSI IA T.17CTR 5 FT. STORIES TYPE CONSTRUCTION
y322 will do the work.and the structure is not inmmdedoroffereJ forsale(Sec.'IU44,Busincss�
and Professions Crile:The Conuacmrs License Law docs not raptly to an owner of
property who build,a,imp rovits lherc—,tad who docssuch work hince for throughhis \
employee..prwided m.va,h imprnvemems arc not intended oreffered fursale.if, OCC.GNOUP RES.UNDS
however,the building orimprovemetn is sold within one yearefcompletion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for putpmc of
sada). QTY. Pl, 1 ) RMIT FGIi
❑ Las nwnendlhepropeny.atm exclusively ronuacting with licensW atmmemrsm 11,000 LONE APN
onstram the project(Sec.70el Business rod Professions Code:)The Contractors
License Law Jtwxnot apply term ownernrproperty who builds or impmves theneon,and PERMIT ISSUANCE
whocommes formch projects with acotnractorm)licensed pursuant mme Contractor's ALTER-DRAIN&VENT-WATER IA
License Taw. ( ) FEC SUMMARY
❑ 1 nin exempt under See ,B&P C for this reason BACK PLOW PROTF,CT:DEVICH OUTSIDE FEES
SANITARY YN
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF, GOND. SCHOOLTAX YN
❑ I hcrcbyinfrm that l havereirlifienk,of consenun self-insure,or.a cenifialc nl' PIX9LRIS-PIER'I'RAh RECEIPT 0
PARK ItIEL Y N
Workm'Compensalionlnsumn oracmiBWcopy Ncreof(Sce.39W.1.ub CJwhich
covers all employees under this Permit GAS-EEA.SYSTEM-1 INC.4 OUTLETS RECEIPT X
Policy# BUILDING DMS NFEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI{ECK IIJi
❑ Cenifieicapyishembyfumiind.
❑ Certified copy is EleJ with the city inspeminn division. GREA$FANDUSTNL WASTE INTERCEPTOR GRADING FEE
C12RTIRCATE OF F- EMPTIONFROMWORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Ihis,ertinnnced not be completed ifthe permit is farone hundred dollars 1$100) SEWER-SANITARY-STORM EA.20(A-p. ENERGY FEE
unless.)
I cenifythat in the peofo.....f the work to,whichthis per mit is issued,I shat] WATER HFATER W/VENT/ELECfB
not employ uny Person in any n anners t as it)become subject to the Workers'' WAl'IR SY53P,M(fREA'1'ING PAID Dane Receipt p
Z Compensalianlawsof Caliminis. Dalep
Applicant S
Z 0 NOTICE TO APPLICANT:If,after narking this Certificate of lExemptlma.youshoulJ NEW RESIDENTIAL PI-MB. Q. TOTAL:
r zi became subject to the Worker's Contpcnsaluen provisions of the LUMr Gude,you must 1
� 7 fordwuh comply with such provisionsanhis permit shall be demed
erevoked. BUILDING FEE LO
OW.. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the peffortttunce of TOTAL: F1.ECENIC FEE
U Q the work far which this permit is issued(sec.309].Civ.C.)
Lead..'.Name PLUMBING PGH
W FF tender's Address QTY MECHANICA.PERMIT F ;E
O U I certify that I have mad this application and stale that the above infomntion is MECHANICAL FEE
>" W cortecl.Iti,mtto comply wahall city and county ordinances and amte laws relating to PERMIT'ISSUANCEi
F bu dingconstructien,and hereby awhorize representatives of this city to anter upon the CONSIRUCTIONTAX
U z above-mentioned property for inspection purposes. ALTIER OR ADD C
Z (We)agree In save,indemnify and keep harmless the City of Cupertino against
Iiabilitics,judgmmnts.coals and expenses which may in air,wayaccrueagainslaaid City IRH D 1 YTO1Iy000 A )
in ryence of the gaming o rs permit. IRI .NG UNIT(OV 0.( )
ik
tgnewrt ofd enUCon¢ann Duro HAUS OOD l(�O PAID
HAZARDOUS MATERIALS DISCLOSURE ' TING UNI' ( I .000 BTU)' Date Receipt#
Will the applicant art future building tecvpant,store or bundle hmWous malrotil 'TOTAL:
az defittW by the Cupertino MYOICIPaI CWe,Chapter Y.l2,and the Headband Safety H' TING UNI'I'(OVIiR It]O,fNK16l'U)
Code.Section 25532(a)T V ILATION FAN(SINGLE RESID)
❑Ycs ❑No
Will the appl icant or future building cecupanmsc tw
cquipm ordevices which emit P
BO .ER-COMP OR IWjW BTU) ISSUANCE DATE
ha ar dous air contaminants as defined by the Bay Arca Air Quality Management BOI ER- P(OVER I000hh BTU) - -
District't fry
❑Y. ❑No NEW RESIDENTIAL MECIL SQ.FT. OCTI have mail the hard
vaoun materials requirements under Chapter 6.95 of the t C4199
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not conically have a asta m,that it is my respansibility to notify the
occupant of the mgaireninds which must be:net prior to issuance of a Certificate or ('I I UYtH I IP I
aeapanay. �'�ldf D(
Owner nr amhorimA agent Dae TOTAL: ISSUED BY:
OFFICE