28285 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO J ILDLNG-ELECI'RICA]. PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 28285
] p O C
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICA'TION LO OJ
BUILDING ADDRESS: SANITARY NO.]APPLICATION SUBMITTAL DATE
, J IJNI"fM LOT#
OWNpNS yAMG: � PHONE: CONT CTO AMP G LIC ND.
Y//V/ 11
NIC CONTROLp
ARCHITEC ENGIN ;R: LIC NO: AID ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT IN
/ 974-ice- PLRMH'ISSUANCE BLDG LECr PLUMB ❑
MECH
"❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. ION DESCRIPTIONpyz, Iherebyafftrm that l am licensed underprovisionsofChapter9m
(comencing with
Itfoo Section I0IXbdlO v,mn3o he Business and Professions Code,nnJ mylic.roeis in PANELS �-
y�UW full force anil
Zm Liccnu 1 s UP T02W AMPS /v�
F
F?y Dam ComrvuuJCr��'i`i� 201-IglO AMPS
ZOvrns�' RCHITECI'S DEC J C OVER 1000 AMPS SQ.FT.FLUOR AREAE/SQ,FT.
Dy.,p Iundc"'and myplansxhall beuscd mpmbliencnmis.
GN ns11 SIGNS ELECTRICAL
dgy�J Licamed Professional
RV OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
U I hereby affirm that I am exempt from the Contractor's License Law for the
W3 Wm I'mll,wing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER Olt POLE INS 1.
C�� which requires a permit m consumer,ape,improve,demolish,or repair any stmcture
i� prion,its issuance,also requires me applicant forsuch Permiu,file a signed statement POWER DEVICES
<0 that he is licensed pursuant tto the provisions ofthe Conimcmrs License Law(Chapter
L e� 9 lcommenebtg with Section 7000)or Division 3 ofthc Business and Professions Code) SWIMMING POOL ELECTRIC _ VALUATION
yYj❑y ,r that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F_Za Section 7031.5 by any applicant for a permit subjects the applicant OIfT1.fiT5-SWITCI IIS-IIXTURES
o a civil penalty of
a.,ownethnn five hundred dollars($500). NEW RESIDENTIAL ELECI'N _SQ.FT. T
❑ I,nsowneloftM1epropcdy,nrmycmployees with wagesmtheirsolecompeneation. STORIES TYPE CONSTRUCTION
will Jothe wwk,and the structure isnot iweaded,rofrered fo11a1e(Sec.]044,Business
and Pmfessionv Code:The Contractor's I.icerlse Lew does net apply man owner of
property who builds or improves thereon,and who does such work himselfor through his
employees,provided that such improvements e not intended oroffernl forsalc.If, OCC.GROUP RIS.UNITS
hoer
wcvc,the haild'mgmImprovement ix sold within Anayevof wo,al,naw,the owner- 'TOTAL
builder will hnve the burden of proving that he did not build or improve for purryrse of
sale.).
❑ Las owner ofthe property,amexclusivelycormacting with licensedcontmeostm QTY. PLUMBING PERMIT FEE Fl.00D ZONE APN
Linstruct the project(Sec.9M4,Bmincct and Professions Cale:)The Contractor''
icense Law docs not apply to an ownerofpropeny who builds or improves thereon,and PERMTTTSSUANCE
whncontrrelsfntatch prnjcas withnromracmq')licased pursmunuothe Cnntmnor's ALTER EA
License Law. 1 ) FEE SUMMARY
❑ I am exempt under Sec. ,H&P C for chis reason BACK FLOW PROTECT.DEVICE SANI'T'ARY TVD N
Owner Due DRAINS-FLOOR,ROOF,AREA,COND. RECBIITN
WORKMAN COMP12NSAIION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofcon'enr to self-insure.or a certificate of FIXTURES-PER TRAP RECEIVrp
Workers'Compensation lnatmace or acenified copy l here,f(Se,.lgm,Lab CJ which PARK FEE Y N
covers all crop ye yl yo-�, GAS-HA.SYSTEM-] O S - RECHIVI'k
PolicyM r/ (¢ LF BUILDING DIVISION FEES
Cnmpan GAS-EA.SYS} -OV 4(EA) PLANCHECK THE
ertif ed copy is hereby fmmished.
❑ Candied copy is filed with the city inspection division. GRHASEdNDUSTR AS'fC I CEI'I'OI2 GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKFRS' GREASE*I7KAp\y SOILS ITE
COMPENSATION INSURANCE
(Thi,,cnion need nm be completed lithe permit is loran.hundmA dollmt(E100) SEWERS 1'ARY-90M ,A.2WFT. ENERGY FEE
or
(certify that in the performance ofthe work forwhich this Permit is issued,)shallTER EATER W/V' /1:LECIR
not employ any persons sin any manner an as to become subject to the Workers' PAID
Cmnpene:vino haws of Cnllf,miu. DateW YSTE R- NO Date Raeiptp
O O NOTICE TO APPLICANT.If,after making this Cedificate of Exemption,You should NEW R I EMI.P'IAB. SQ.IT.
T A
H t(q become subject the Worker's Compensation pwvisiom ofthe labor Code,you must
BUILDING PGE
� ? finchcomply with such provisions or this pernitshall be deemed revoked.
OW.I Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z I hereby affirm tha ,hwe is a communion lending agency(.,,he performance of
V O the work for which this permit is issued(Set.3097,Civ,CJ TOTAL: ELECTRIC FET
Lenders Nome
P.
U Larder,Address Q'I'Y. MECHANICAL PERMITFEE PLUMBING FEEI oddly that 1 have sad this application and state that the wove information is
correct.l agree to comply with all city=(county ordinances and state laws relating to PERM IT ISSUANCE MECHANICALITE
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
L.1 Z uhave-mentioned property for iexpardwr purposes. ALT Ii It OR ADD TO MEC(I.
(We)agree m save,indemnify end kap harmless the City of Cupeninn against
Iiabilities,judgmems,contend expenses which may inany wayacerueagaim,said City AIR I IANDLING UNIT CIO 10.000 CFM)
in consequence of the granting of this permit.
AIR IIAN DLINO UNIT(OVER 10,000 CPM)
Madame,of ApplinumfComfecer, Data EXHAUST HOOD(W/DUCf)
PAID
HAZARDOUS MA'I'12RIA13 DISCLOSURE HEATING UNIT('10100,000 HT U) Date Rac,p.N
Will the applicant or future building occupant store or handle hamrdous material HEATING UNIT IDVER 1011,0(10 B'rU)
as defined by the Cupertino Municipal Code.Chapter 9.12,end the Health and Safety
Code,Section 8532(')?
❑yet VENTILATION FAN(SINGLE RISID)
BOIhI?k-COMI'(311P OR IIHI,000 BTU) �' ISSUANCE E
Will 1hcapplicanmrfumrehuilJingaec� nOtuseequlpmemordevicawhich emit t� V 0
hamict? air mntaminent m def the Ba Area Air
y Quality Management BOILER-COMP(OVER 100,000BTU) A{0
District? Note
❑Yes No NEW RESIDENTIAL MSCI I. SQ.1'f.
read the hmnrdous material'rea mremews under Chapter 6.95 of the Clot 1 1995
C tfo a plealth&Safey Code,Smaons 25505,25533 and 25534. 1 understand man Vh LVr
ifthe hralling docs not rpMatly ha...t teduarn. Is itis es n bibty
cccdiAr�o requlr tent pdm rot nectar,
Oce we,
Owner o .athorized agent Data 'TOTAL: ISSUED HY. g
OFFICE