28255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO x B.DI G-ELECTRICAL. PLRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 28255
BUILDING DIVISION BUILDING PROJECT]DEN']'1FICATION
HUILDING ADDRESS: p/ p SANITARY NO. APPLICATION SUBMITPAALL DATE
UNIT - LDTg
NAME:LMPRIC
�OW F. .St \
7
N/C CONTROL#
iSRC111'1'HC'1'/ENGINLLR: LIC NO: ADDRESS: ❑
Z�
CCONTACT: PHONE: BUILDING PERMIT INFO
' QTY. ELECTRIC PERMIT PEE
RLDG .F.CT PLUMB 110PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 DESCRIPTION
ID El
pyZ I hereby affirm that l em licenudunderpnrvisionsofaapter9(commencingwith
�00 Section 70011)of Division J of the Business and Profusions Cade,and my license is in PANELS
ydE full to.cad effxt.
Fa- W License Class Lie.a UP T0200 AMPS
w oo Date Contractor 201-I0N)AMPS
20y� ARCHITECTS DF.CLARAI ION OVFiR 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
02,O 1 understand my plans stud[be used as public records.
F rn I=W SIGNS ELECTRICAL
=W7, Licensed Professional
�Well< OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aOyF 1 hereby air.that 1 sen exempt from the Cnnuucou's License Law for the
t 3�wfollowing reason,(Section 7071.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Jj
Owhich requires a permit to ennsuuct,alms,improve,demolish,or repair City ewcturc
CC�;!I}2 priml.iuisuanCe.elso requires the applicant for such perout to Idea signed statement POWER DEVICES
W�G O that he is Iicensad pursuant to the Provisions of the Contractors License law(Chapter
d z 9(commencin th Section 70001 of Division J of the Business and Professions Code SWIMMING POOL ELECTRIC
o LL. 6 car ) VALUATION
❑w or@m M17031.5 by my
yapplicnt tura buisfnnjects thedexcmptt to civil
of OUTI.Ii TS-SWITCIII:S.FIXTURES
�. C
Sectionoe 7031.5 by hundred
dollars($50 nit subjects the applicant civil penalty of
g 0 or me than Live hundred dollars($500). NEW RFSIDENTIALELECIR —SQ.PT.
6' o n❑ oche the structure
offered
f wagarsthei See,` ,Bwa assSTORIES 9'YPE CONSTRUCTION
L3-e and dothssionsnde: nmctureisno's License
Law
7oa4,Business
and eflyProwho
Code:The Contractor's License Law does not him to an owner of
prnpeny who builds or improver thereon,and who docs such work himulfor through his
employees,providedthut such improvmnemsorenmintendedon#fend forsola.
If, I OCC.GROUT' KLS.UNITS
haw er,the building or improvement is sold within one yearofcompletion,the owner.
builder will have the burden m,noving that he did not build or improve for purpose of
sale.).
❑ I,as owner.fttepropcny,um cxdusivelyc.mrooing witnlicensed conwnonm QTY' PLUMBING PERMIT FEE ON F APN
construct the project(Sec.7044,Business and Professions Code:)The Connector's
License Low does not applym an ownerafpropeny whobuilds or improves thereon,and PERMITISSUANCE
Who contracts for such projects with aconmelonr)licensed pursuant to the Contrecmra ALTER-GRAIN&VINT-WATER Fit
License Law. ( ) FEE SUMMARY _
❑ I nm uempt under Sm. B&P C for tM1ir reason BACK FLOW PROTECT.DEVICE SANFAR Y DEDE T N
Owner Dote RECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,COND. SCHOOLTAX Y N
101FIherchY afOrm[hatl h�vea Cerificme ofwmsem to self-insum.ora certificate of RECEIFTp
ker%Compensat5iaorn�lnCwrrens,cpeeor acertifedcupy thereff(Sm.7800,Lab C.)which FTXTURFS-PER TRAP PARKFEE Y N
covers all emplpyee`U th rL-i tqO d RECEIPT p
WW a_A/ L GAS-PA.SYSIEM-I INC.40IITLETS
Policy N BUILDING DIVISION]EFS
Company. -Q- GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ CeniOeA ropy ie OleA with the city inspccsinn division. ORT?ASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
rLdsscuti.n neednot be completed ifflm .it is for one hundreddo11ao($100) SEWF.R-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icenitythnt in the perfomwnce of the walk for which this permit is issued,[shall WATER BEATER W/VENT/ELECI'R
not employany person in any manner an as to become subject to the Workers' PAID
Cum,amennalawsof Califomia. Da¢ WATER SYSTEWE EATING Data RaeiptN
Q z Applicant
�csy NOTICE.TO APPLICANT:IL after making this Certificate of Esempti.n,you should NEW RESIDENTIAL PLATE. SQ.FT. TOTAL:
r V] become subject in the Worker's Compensation Provisions of the Latour Code,you must
R forhwh h Comply with such provisions or this permit shall be deemed invoked. BUILDING FRE
y (] CONSq'RUCTION LENDING AGENCY SEISM IC FEE
z I hereby affirm that thein is a Conswction lending agency for the performance of
V O the work for which this permit is issuW(Sec.7(197,Civ.C.) TOTAL: ELECTRIC FEE
(L Lenders Name
Lenders Address QTY. MECHANICAL PERMIT PIiE PLUMBING FEE
�J 1 certify that 1 have rcod this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingcomuuction,and hereby national represcntadvesofthiscity memo months,
V above-memiomed property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmleas the City of CLpenim,against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT PTO 10,000 CFM)
in Co.se ucnce nl'the gmnt/m�y his permit. y
2Q' — AIR HANDLING UNIT(OVER 10,0(10 CFM)
SigSl ApCommctur Data EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE ]]EATING UNIT(TO IO LDN)BTU) Date Receipt is
Will the applicant or future building occupant store or handle bcoandous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety BEATING UNIT(OVER 100,000 ETU) TOTAL:
Cade,genion 25532(a)?
ED Yes El No VENTILATION FAN(SINGLE RESID)
Will theepplicanmrteam miffing uccury nmuequipmcmodeviceswhichemit
BOILER-COMP(JHP OR IULD00 BTU) ISSUANCE DATE
hazardous air c rmaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I(NI,IXq BTU) ID�
District? 0
❑Yea El No NEW RESIDENTIAL MECII. SQ.FT.
I have reed the hasuargaSafety
Com materiels rc05,255 3 under Chapter understand
of the ,� .5���
California Iladth&Safety Code.Sermons 25305,l it is and 25574. 1 undersand that /
if the holding doesnoeunts lyhave asenate,e, itis myresponsibilityeinotifythe
O
occupied of the requirements which must M1e met prior m issuonee of a Certificate of f
Occupancy.
#^
pancY.
Owner or nmhoriud agent Dam TOTAL: ISSUED BY:
OFFICE