28217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 28217
HUILDIN SS: SANITARY NO. APPLICATION SUBMITTAL DATE
OT#
OW .RSN ONE: CONTRAC' �-2'SNA LIC NO:
N/C CONTROL#
1RCHITI3C]'/E GINL LIC NO: ADORES ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E .Cp PI E_CI
PERMIT ISSUANCE -
LICENSED CON IRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
therebyaffirnthatIambe.medunderprovision.ofChapter9(mmmencingwith
P400 Sectim700(h flAwisioa3ofthe Business and lhofe..irns Code,and my license is in PANELS
yd fail License
Class effect. UPT0200AMPS
GZ License Class List.
y60- Date Comrecmr 201-1000 AMPS a.Rrlt 0'
ZONZ ARCHITECTS DECLARATION OVER idAMPS - SQ.FT.FLOOR AREA $/S !T.
O z'-'❑ I underaanA my plmts shall be awed es public records, (] P }�`y
TNF', Licensed Professional SIGNS ELECTRICAL —L 1111V1]_ w
Q OWNER-BUILDERto DECLARATION SPECIAL CIRCUIT/MISC.
qq 00.E 1 following
greas nffmm that 1 am exempt from the Cosigns o License Law for the
7X¢1 jal-N which requirsaeemit(Section
to 7031S,Business sines and Professions Code:Any city or county TEMP.METER OR POLE INST.
Jwhidtrequire.ap'.1.toconssthe alter,improve,h pealish,fi repair anystructure P2 (hit rto heslisuued pursunt tthe provisions
rvisios of the Comermivo Licele a nse
La smmment POWER DEVICES
W O thatheisncin.eAth Sectiomthe provisionsof the Commands Llmnsc Law(Chapter
d 9(crmmen ' with Section 7000)of Divinion3of the Business end Professions Code SWIMMING POOL ELECTRIC �
E, c�mg tui ) ^ VALUATION
yl❑y Se@at he 111.1b an""romnnd the basis for bedexemptirn.Any violation of
[.. Q 1to
% 9031.5 se anarned!eantfoeapumit xubjerus the applicanuo..civil penaltyof OUTLETS-SWITCHES-PIXTURLS
^�
re
re
five hundred dollars($SfNH. NEWRESIDENTIALELECTR S .FT.
mWm nwnerofthepmperry,ormyemployeeswiuh wagesastheirsolecompensmirn, Q STORIES TYPE CONSTRUCHON
y 11 do acwerk,nndihamnmmto knot intended oroffemd forsale(Sce.9014,Business
and Pin i ns Cade:The Contractor's I,erne Law draw not apply m an owner of
property slSbuildsrrimpmves thereon,and whodocs such work himselfonhrrugh his
.wrempki,eca,acisidolthitainch improvcmemsareaot mmadrdoroffered forsnlc.If, OCC.GROUP RES.UNITS
however,the building m aropmermantis sold within one year nfcompletion,the owner- TO
builder will have the burden of proving that he did not build or improve for purpose of
solo.). - - x
❑ I,as ownerofthe property,am exclusively contracting with licensed contractors m QTY.-:, - PLUMBING PERMIT ` FE8 FLOOD ZONE APN
consumer the project(Sec.TAT Business and Professions Code:)The Contra....'.
License Lawdoes ort applymanownerrf pr..pertywhobuildsorin oves nation,am PERMIT ISSUANCE
who nmtruc[s for such projects withacrnira<roti.)licen.ed pit..aZothe Corametion, AL'IGR-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law. ) -
❑ 1 am exi mpnmder Sea ,B&P C for this reasonUTSIDE FEES
HACK PLOW PROTECT.DEVICE SANITARY YN
Owner Date DRAINS-FLOORROOF, CONIRPI-171"., , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby affirm that l have a cenificam efcousennoself-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
Wmkoo'Compensmion I....aneema ccniBed copy theomf(Sec.3800,Lab C.)which PARK FEE Y N
mvem all employee'.mader this permit. GAS-P.A.SYSTEM-1 INC.4 OUPLETS RECEIPT#
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(PLA) PLANCIIECK FEE
❑ Cenlficd copy is heminy famished.
❑ Certified copy is filed with the city inspection division GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASF,TRAP SOILS FEE
COMPENSATION INSURANCE
(This srctlonneed not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-ST EA.20BPT
car less.) ENERGY FE
Icen,fy that in the pertomtarm of he work for which this permit is Bsued,l shall WATER HEATER W/ TALEC
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Culifern.. Date WATER SYSTEM/ n TIN DamZ Applicant
Re ipt#
Z Nat ICE TO APPLICANT:IL afErmakir this CediGcate ofli,ma ion,y..,h.ald NEW R. P. PLMB. S .PT.
6 Q
became"hwim imply the Worker's Comnsiarfosprovisions ofthe Labor Code,you must TOTAL:
C� , fonhwirM1 comply with such provisions Tobi.permit shall he deemed revokrA. BUILDING �r
ala CONSTRUCTION LENDING AGENCY ss� SEISIM
.�Z) Z I hereby uBlrm That theve is a mos matioa lending agency for the Emmor anoe of EI F
U 0 the work for which this permit is issued(Seo.3097,Co.CJ
Lenders Nome -
O U Lender's Address QTY. MECHANICAL PERMIT= - FEE
PLUMBING .E LIU
U 1 certify that 1 have rend this application and slate that the above Information is
0.Wi correct. Ingres to comply with all city and county ordinances and state laws retain,to PERMIT ISSUANCE MECHANI ALFEE
building construction,and hereby authorize representatives ofuhis city to cnreruponnuo
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONS] MON TAX
(We)agree m save,Iaaenmify and keep harmless the City of Cupcnin last
liubilities,ju a,costs and expenses whm may ywa seer u . d'aid City AIR HANDLING UNIT(TO 10,000 CFM)
memne nmol g inGig It.
AIR HANDLING UNIT(OVBR BLOW CFM)
Si mm.f t on[ or Orae EXHAUSTHOOD(W/DUCT)
PAID
HAZAR US MA'T'ERIALS DISCLOSURE IIEATINGUNIT(TO IW,UWBTU) Date Receipt#
Will the applicant or future building necmpamt store or handle hazardous material HEATING UNI'T(OVER IOO,OIq BTU)
s defined by the Cupertino Municipei Cade,Chapter 9.12,wd the Hwlih and Safety
'.de,Section 25532(a)9 VENTILATION BAN(SINGLE RESID)
❑Yes ❑No
BOILER-COME(314P OR 1IXkIXq BTU) ISSUA CE DATE
11 Will Neapplimnt or furore huilAingoccupam useequipmem ordeviceswhich emit .,
usair contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
strict?"
❑Yeo ❑No NEW RESIDENTIAL MECH. SQ,PC AUG O V(^ ����
I have read the hazardous materials requirements under Chapter 6.95 of the
California health&Safety Code,Sections 25505,25533 and 25534. I code....nd that
if the building does net meren ly have a minor,that It Is my responsibility to notify theCII Y
occupaant of rhe na mine is which must be met poor In ismncoe of a C nificote of Uf 'Ur -I INU
Occupancy.
Owns o,authot'z dugs Date ISSUED BY:
OFFICE