28401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
[OWN
ITY OF CUPERTINOPLUMBING''' .— J.l."HICAL PERMrrnO.
BUILDING DIVISION APPLICATION/PERMIT PROJECT
2 8 40
1
BUIL I,YG PROJECT IDENTIFICATION
UILDING ADDRESS: _ SANITARY NO. APPLICATION SUBhffITAL Dj`TEJ d Y+ UNIT. LOtb _ERS NAME: ��<x-�a PHONC: CONTRACTOR'S NA.31�� LIC NO.
NIC CONTROL.
ea c ec ! 0 r L 3 3 Y'
�IITE-CVENGINEER I LIC NO, ADDRESS:
CONTACT: PUONE:
QTY. ELECTRIC PERMIT' PEE BUILDING PERMIT INFO
O V i J �_/� �' BLDG ELECT PEE MECH
PERMIT ISSUANCE. ED El
❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pzZ IM1ereby aflimt taW errs licensed unJerproviaions Ol'Chup¢r9lcommencinguith ���sss' ` IOD DESCRIPTION
''-CC Sectimi'7000tof Division3Ofthc Bmimessund Profe.sion Cndrandmy license out PANELS
yJU but force and Ofe<}�. ILMI TRK— I
BZW License CTass _Lic.x L Z 33��1 UPT02IX1AMP$
Dale Connector]w' Tt,' V'ac� 201-1001)AMPS
A CHRECTS DECLARATION OVER 11)fA AM11P5 SQ.FT.FLOOR AREA S/SQ.17.
l understand my plans shall Is,used as public records.
y�? SIGNS ELECTRICAL
rocz¢ Licensed Professional-occe<
sOWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
....
1 hereby affirm that 1 am exempt from the Contractors Code:
License Law for the
�LCN Which ngremoo.ermit to
mftx Busfter,iprve.dmoli Cute:Mycity orcountyTEMP.METEROR POLE INST.
y J which require.a permit to eoaerua6 alter,improve,demolish,or repay any arvcmrc
Eac T� to ininused pursue sires thea provisions
Co POWER DEVICES
prior y pp permiuO fileasign<d smmmem
s C C the he is licensed pursuant the provisions of the Contractor Limns Low(Chapter
=a9lrommencing with Section 11)001 of Division]o(te Business and ProfessionsCom SWIMMING POOL ELECTRIC VALUATION
V_yor he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTIIRES
-ZQ Section 1031.5 by any applicant fora permit subjnuthe applicannoucivilpetalnof
—O
no,more than rive hundred dollars($500).
zE� ❑ I'm owner of the properry,ormyemployees with wages in NEW RESIOLNTIAL ELECTR _SQ.FT.theirsolecompematian. STORIES TYEBC N TRUCTION
y3— will dodo,work.andtbe inseam isnm im,nded,ndficred formic(Sec. Business
and Pmfnsinna Cale:The Commcun,License Law don not apply m an owner Of
property who buildsor improves menton.and whodoessuch work himidimughbi. OCC,GROUP RES.UNITS
employnyprovidcd Oat uch immrcim
pmveemsanot cndedoroffcrtd forsale.If.
however,the building or improvement is sold within me year of completion,theouner- TOTAL:
builder will have the burden of proving that he did tat build or improve for purpose of
rale.
❑ 11,as owner of the pmpcny.amexclusiverycormacting wit liceadcon¢actors to QTY' a PLUMBING PERMIT .;,� FEE FLOOD ZONE APN
conatrvd the project(Sec.]04.Business and Professions Code:)The Contractors PERMIT ISSUANC
License Law does not apply m an ownerof property who builds or impmvn thcean,and
whocontracts for such projects with admoacmgs)licensed pursuunuote Contractors pIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reasonBACK PLOW PROTECT.DEVICE OUTSIDE F 17
SANITARY Y_N
4kner Date DRAINS-FLOOR.ROOF,AREA,COND. RCCCIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
(hereby uffimt thin haveacmificate of conunno set Linsue,or acenifi ate of FIXTURES-PER RECEIPrx
Wurkers'COmpenaaion frommnce ora cenifiedcopythereof(Sec.Jggl.Lab C, which PARK FEE Y N
coven all employee's under tis Permit. / fq GAS-EA.SYSTEM- .J OUTLET RECEIPT X
Policy X BUILDING DIVISION FEES
CO.P., ^" AS Y 40V J1
❑ Cenifed copy is hereby famished. PLANCHECK FEE
❑ Cenifid copy is filed with to dry inspection division. SEf LW INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' SE SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted if to Permit is parent,hundred dollars($111
SEWER-SANITARY-STORM EA.; ENERGY FEE
or leu.)
I ccnifytbut in to pedahurd,of to work for which this permit is issued,(shall WATER HEATER WNENT/E
net employ any person in any manner so as to became subject to the WorkersPAID
Z COmpenemion LOvidCallfemia. Dme WATER SYSTEMrmR. NG Date Receipt#
Applicant
z C) NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDEN LPLMB. SQ.FT. TOTAL:
V] burome subject to the Workcrs Compenuuon provisionaftht,Lear Cale,you must
forthwith comply with such provision.o..his pemia,mil he deemM evoked. BUILDING FEE
.'J 25
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that hem is a construction lending agency for me performance Of TOTAL: ELECTRIC FEE
eJ the work for which mis period,is issued(Sec.3097,Civ.C.)
Lander'x Name ,. PLUMBING FEE
Lenders Address QTY
—MECHANICAL PERMIT - FEE
I certify that 1 have mad tis application and see that the above information is MECHANICAL FEE
Z c nett I agree to comply with all city and county ordinances snit sae laws miming to PERMIT ISSUANCE
h building construction.and hereby sutodm representatives of this city to enter upon the CONSTRUCTION TAX
Z above-mentioned
property for inspection purposes. ALTER OR ADD TO MECH.
I W<I agree m save,indemnify and keep harmless the City of Cupertino room,
mbilities,juJtlmcmv.costa an der eswhichmayinany way accrue against saidCiry AIR HANDLING UNIT fT010,0(I(1 CFM)
con;Z of grani irixes hie
7 -17 rS' AIR HANDLING UNIT(OVER 10,"CFM)
Sigrat . Applicum/Contmdm Dec EXIIAUSTIIOOD(WMUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I100.000 BTU) Dole Receipt#
Will the applicant or future building occupant store or handle motadon material HEATING UNITIOVIiR❑p.OW BTU) OTA
ss defined biy the Cu,Pd m Municipal Code.Chapter 9,12,and the Health and Safery
Cods.Section 23332(a)'
❑Ycs ❑No VENTILATION FAN(SINGLE RESID)
Will tea livanmrfumrebuildin yuipmen - DOILGR-COMP(lf1PON IW,W1)Bill)
SSU DATE
PP gacupanmsec tnrdeviceawhichemt
mrdous air conmminmrm as defined by the Day Area Air Quality Management BOILER-COMP(OVER 100.IXI11 BTU)
tater!
❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the haeardom materials rcyuimmene under Chapter 6.95 of the 1"1 A
Culifomm[]earth tit Safety C.O.Sections 25505,25533 and 25534, l understand tat •1/
Oslo
if the building dna not currently have a tenant,that it is my responsibility to nmifv to
'capam of the requirement.%which must Is, not prior In issuance of a Cemrtcae of
Oecupuncy. '^`,�
Owner Or amhoriaeJ agcm Ilam TOTAL: ISSI)FJJ iv:
OFFICE