28365 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUHANNG-ELEC I RICAL PERMIT NO.
APPLICATION/PERMIT - PLUMBING-MECHANICAL -
BUILDING DIVISION - , BUILDING PROJECTIDENTIFICATION"
28365
BUILDING ADDRESS: SANITARY NO. APP
LICATION SUBMITTAL DATE.
4 UNIT# LOT#
O I2S NAME: 1 $A PF ONE: �_�� CONTR 1'OR'S NA-MF�n LIC NO: N/C ( CON'PROL#
AMC[ I'ECT/ENGINEER: 1WLIC NO: ADDRESS: \�TV1`�`/►�/ ❑
coNTACI`. PHONE: QT,)( - '," - ELECTRIC PERMIT NEE BUILDING PERMIT INFO
BLDG a ECT o# PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GadZ I hereby affirm that l am licensed anderprovisions of'Chvplcr9(commencing with xJOB DESCRIPTION
{ 00 Section 70000of Division 3of rhe Business.and Prnfessinns Code,and my license is in PANELS
QQ ly
License Class Lic.# UP TO 201 AMPS
so Date Contractor 201-1000 AMPS
ZO on T7. ARCHITECTS DECLARATION OVER IOW AMPS SQ.PT.FLOOR AREA $/SQ.ET.
O Z—p I understand my plans shall he used as public recoMs.
Pm IL SIGNS ELECTRICAL
9�C Licensed Aofeseional
mm OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
qq O p+F I hereby n.affirre(Se that 1 am exempt from the Contractors License Low for @o
IXil30.y which
following reason.parction..a..5,Business and Professions emoli Code:Ar city.,rnture TEMP.METER OR POLE INST.
which Michas npeyotl,re quires the alley,imp rove,demolis h,ere a siiganyswctnre
f°t+0
prior
at110it lissuved pursuant
nt to the
the Co pemdr(oLice signed statement POWER DEVICES
� Ap that bo is licemW pursuenrio the pmvlcions of ilia Contractor's License Law(Chapter
P•yo 9(commencing with Section 9000)at Division 3 of the Business and Professions Code) SWIMMING p001.ELECTRIC VALUATION
W%_,y or that he is exempt herefrom and rhe basis for the at leged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
4 Section 9031.5 by any applicant for a permit subjects the applicant to a civil penally of
5W p
not more than live hundred dollars P1500).
I,aswneroflhepmperty,ormyemplnyeewilh wagesastheirsolecompnsati NEWkESl0ENT1ALELELR S .PTon,
STORIES TYPE CONSTRUCTION
y will do the work,and the structure isnotintended proffered hassle(Sea.9044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
properly whobuildsorimpmves thersogand whodeses such workleimselforthrough his
employees,provided that such improvemenrsom nolinteaded oroffereA consuls.If. OCC.CROUP RES.UNITS
however,the building or improvement is sold within one yearof completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.). '
❑ las roftbepmperly.amexclus velyconvauingwilhlicensd convectors to QTY: 'PLUMBING PF.RINIFF . 'FEE F-TOODZONF. APN
Oconal then Forces.(Ser.7044,Business and Professions CndeJ'ITB GOn[mClor9
License linen does not appiyro anownerofpmpeny whohuilds orimproves thereon,and PERMIT ISSUANCE
who contracts for such pmjecls with aconvacmro)licensed pursuant o the Commmors ALTER VENT-WATER EA FEE SUMMARY
LicenseCaw. ( )
❑ I um exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECF.IPI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherehy affirm lM1etl hvveacvlibwleoPoOneenuo self-insure,ore vertiMme of FIXTURES-PER TRAP RBCEIPI'#
Workers'Compensation Insurance ora unified copy thereof(Sec.3800,Lab C.)which PARK FEE YN
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANE]IECK FEF.
Cl Certified entry is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE.INTERCEPTOR
GRADING FEE -
CERTIFICATEOFEXEMPfION FROM WORKERS' GREASETRCPN SOILS FEE
COMPENSATION INSURANCE
Oils sectionneW not he complete ifrhe permit is for one hundred dollars 1$100) SEWER- NI Y-STORMEA. 0 ENERGY FEE
or less.)
Icertify that in the perfonnancc of the weak for which this permit is issued,i shall WA ER W/VP.NT..
not employ any penton in any m as m become subject m the Workers' PAID
Z
Compensation Laws of California. Dare so RSYSTEM FATI Dale R p
O Applicant
NOTICE.TOAPPLICANT:ILofmrmakingrhis Cenificenanf Exemption,you should WRESID L D. SQ.FP. TAE:
t•^ V] become subject o the Workers Compensation provisions of the].shot Code,you most
•`a' 5 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FE
W Q CONSTRUCTION LENDING AGENCY SEISMICFEE -
rZ I hereby affirm Char them is a construdion lending agency for the performance of TOTAL: ELECTRIC EBB
O Ibe work for which this p.it is leaned(SIN.3097,Civ.CJ
LI. Lenders Name a , ,
Lenders Address QTY.>:; MECHANICAL PERMIT f FEE'; PLUMBING FEE
U I certify ilial I have read this application and state that the above informatione ' MECHANICAL f E
r7^ a correct. Iagrea l0 comply whh all rhy and county oNinancrs and slam levee relating ro PERMIT ISSUANCE
�^ building construction,and hereby authorize representatives oflhis cityro inner upon the CONSTRUCTI NTAX
U 7 above-memioned property,for inspection purposes. ALTER OR ADD ID MECH.
�i (We)agree m save,indemnify and keep Lartnless the City of Cupertino against
IlabiRnies,jad ents,msaa dexpenses naeyw acvmeagaimisaid Chy AIR HANDLING UNIT(TO 10,WO CFM)
in mac of the gra rg of i
L ,15 AIR HANDLING UNIT(OVER IgtIW CFM)
s I
Slgnmu AP c oro her ma EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS HRIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building ouupant store or handle hazardous material
m defined by rhe Cupertino Municipal Code,Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100,000 BTU) TO AL:
Code,Section 25532(n)9
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILHR-COMP(3HP OR 100,000 BTU)
1SSUANC ATE
Will the applicant or future building occupant equipment ordevicn,which emit p
bazardops air comaminants as define by the Bay Area Air Quality Management BOILER-GGMP(QYER IW,gNI BTU) �7 Ie, 0 p1
Distrid7 CO
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FP.
I have read the ImvMoue materials noppremems under Chapter 6.95 of the v
California health&Safety Code,Sectmns 25505,23533 and 25534.1 understand that 11/y.Y 1gg�
if the building coax not currently have a[upon[,that it is my responsibility to notify the b I
cupant of rhe reyuiremems which most be at prior to issuance of a Calibrate of
Occupancy. FO
Owner or aulhomal agent Data TOTAL: ISSUED
OFFICE