28038 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIT�ifOFCUPERTINO
BUILTNG ANRICAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PING,PROJECT
CT IDENTICAL
` -BUILD�I/NIG PROJECT IDENTIFICATION .. '
BU
DLOT It
ING Z Ti55: ��� _ ,r UNI • ✓ SgNITARY NO. gPPLICATION SUBMITTAL DATE
OWNERS NAME: ��" '/-$Vw�e / PHONE: �AV� CONTRACTORS NAME: LIC NO: 71
^CONTROI.M
OCHITF, T/ENGINEER: LIC NO: AD RESS: ❑ 4
CONTACT: PHONE: QTY ECF;CTRIC PERMIT FEE,; -:, BUILDING.PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWZ I hereby afnrm that I am licensed underprovisionsofChapter9(commencing with JOB DESCRIPTION
1100 Serion9000)of Divieon3orthe Business and Professions Code,and my license is in PANELS
full force and effort. ,
K UP TO 200 AMPS
dz ly
License
Class LIC.N
ti=y Dale Contractor 201-1000 AMPS
Z��Z ARCHI'TECT'S DECLARATION OVER IOW AMPS SQ.FT,FLOOR AREA $/SQ.ET.
p Z—G 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Ym
�<
Oyu I hereby affirm that 1 am exempt from the Contractor's License Law far the
W 3 m following reason.(Section 7031.5,Business and Professions Code:Any city oncounty TEMP.METER OR POLE INST.
�1 m; which magnums a permit to constacq alter,Improve,demolish,m repair any structure
prouto is issuance,also requires the applicant forsuch pemmit a file a signed sotement POWERDEVICES
W =p that he is lionred pursuant tti theprovisionsof the Continuities License Law(Chapter
aq p 9(wmmendng with Section 900th[Division 3oFlhe Business and Professions Cod) SWIMMING POOL ELECTRIC
W'ny or that he is exempt and the basis for the alleged exemption.Any violation of VALUATION
�Q Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
t refir fvc hundrWddlars($5L0).
0 1,asownernfthe ro er NEW RESIDENTIALELECTR —SQ.FT.
p p ry.mmyemployceawith wogesastheirsolecompensmion, STORIES TYPE CONSTRUCTION
y3=° will work,and the structure isnot intended mofferedforsale(See,7044,Business
and Prefic,somis Code The Contractor'a License Low does not apply to as owner of
prupeny whobuildsor improves thereon,and whodoes such work himselforthrough his
provided'],a'such improvement,ere not intended proffered for sale.If, OCC.GROUP RF,S.UNITS
however,the buildingm improvement is sold within one year ofwmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). - , , . .
❑ I,as ownendmhepropeny,amexdosivelyctimraning wiN licensed conoudoam QTY.'{ rPLUMBING PERMT FEE FLOODZONE APN
timmuct the pr ,jut(Sen,9044,Business add Professions Cwb:)The Coemserm'a
License Law doesnot apply loan ownerofpropedy whobuildsorimpmvesthereon,and PERMIT ISSUANCE
who contacts foriuch proper,whhacomraomr(s)licensed pursuant to the Contractor" ALTER-DRAIN&VENT-
LicenseLaw. WAT. I ) FEE SUMMARY
❑ I am excrod under Sec. ,B X PC for this reason BACK PLOW PROTECT.DEVICE OIJTSIDB PEES
NITARY Y_N
Owner Date DRAINS-FLOOR,ROOF,AREA,COED. RECEIPT
WORKMAN COMPENSATION DECLARATION SCIIOOL TAX YN
❑ ers Compensation
cenmof copytherof(Snaure,or Lab C.)which FIXTURES-PER THAT RECEIPT#
Wtirkera'Compenamlon lnsumnw oraemlfied copy thwwf(Sec.3A0,Lab CJ which PARKFEE Y_—N_
covets al I employee's under his permit GAS-ESYSTEM- INC. ECEIPT N
Policy N A. C.4 OUTLETS BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
❑ Certified copy is hereby furnished,
❑ Certified copy is filed with the city inspection division. OREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE TRAP SOILS PEE
COMPENSATION INSURANCE
(This lesion need not he completed iftbe permit is for one hundred dollars($1Off SEWER-SANITARY-STORM EA.200FT.
or less.) ENERGY FEE
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/F.LECTR
not employ any person in any manner so as to became subject to the Workers PAID
z Compensation Lawsof Califomia, Date WATER SYSTEMUREATING DateRecciptM
Applicant
NOTICE TO APPLICANT:If,after making this Cenificareof Exemption,you should NEW RESIDENTIAL TIME, SQ.EL TOTAL:
H V) become subjort mthe Worker's Compenamlon provisions ofine Labor Code,you..it
> forthwith comply with such provisions or this permit shall be deemed revoked BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I-i z I hereby affirm that there is a conswation lending agency for the performance of
tUO the work for which this permit is issued(See 3097,Co.CJ TOTAL: ELECTRIC PEE
Lender s Name
C) F Lender s Addres, QTY y MHCIIANICAL PERM�Tt ;'FEE.. PLUMBING FTSE
U I eertdy that I have read this application and state that the above information re "U
correct.I agree to comply with all city and county ordinances and slate laws relating m PERMIT ISSUANCE MECHANICAL FEE
building construction.and hereby authomize representatives of this city m emcr upon the
U z move-mentioned property for inspection purposes. ALTER OR ADD TO NIECE. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way nope against said City AIR HANDLING UNIT TO 10,000 CFM)
It, o sc�e� g�g of t� uema � F'�j/n
c Jai//itj1��—' 11AI-1 AIR HANDLING UNIT(OVER I QW0 CFM)
Signature of ApplicanUCotnowtor Dale EXHAUST HOOD(W/DUCS)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Doe Rewiptb
Will the applicant or future building occupant store or handle hartmous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safay HEATING UNIT(OVER 1 W,fical BTU) T L:
Coda Sector 25532(a)1 -
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will lhe air co icantorfuture building by thenDay Area Aen Quality
Managemes which nt
BOILER-COMP(311P OR 10,000 BTU) ISSUANCE DATE
Incurious air cont minants as defined by the Bey Arca Air Quality Management BOILER-COMP OVER 10,0(10 BTII fP
Disrtief! ( 7
AID
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Pf.
1 have mod the hazodtiva mmuivls reyuiremente under Chapter 6.95 of the JUL18199
California Health,@ Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a meant,that it is my malmand ility tu notify the CITY Cir
occupant of the requirements which must he met prior to issuance of a Certificate of (z Uf.-ETz�' /A�/�/1
Occupancy. I1 ��`{�////
Owner or authorized agent Dme TOTAL: ISSUED BynEoq
OFFICE