28123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO B L 1 G-EL CTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28123
'v BUILDING PROJECTIDENTHtlCA7'ION' °
BUILDING ADDRESS: �s .may- SANITARY NO. APPLICKI[ON SUBMITIAL DATE
SCQ��a TV 6L),Q# LOT ft
OWI N / PH E CONTRA 'S NAME: IC
{/V_ \V[�/ N/C CONTROL#
NCIII'IECT/ENGINEEB: LIC NO: ADDRESS: ❑
,ONTACf: PHONE:
QTY. ELECTRIC PERMIT FEE' BUILDING PERMIT INFO
BLDG F:LF❑.l PLUMB MECH
PERMIT ISSUANCE
By
CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ^� 1 BDESC ION �c
7�02
IM17000)ofirmision 3 that ofthnsedinssand EVonsions Code,and
mmeneise is in
Section]000)of Division3oghe Business and Profineions Code,and my license is in PANELS
full force and effect.License Clans Lia# UP T0200 AMPS
Dale Gmlracmr 201-I"AMPS
Z0y
ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
02 ❑ I understand my plans shall he used as public records.
�h '2 Licensed Pmfewural SIGNS ELECTRICAL
�yuu11� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O y F 1 hereby affirm that 1 am exempt from the Contra is License Law for the
613 avi following reason(Section 9031.5,Business and Professions Cade:Any city or county TEMP.MCT ER OR POLE INST.
kz.� which requires a permit to construct,alter,improve,demolish,or repair any structure
NWYS prior In it, waince,.k.w mea licant forsah Permit Io file a si dnmtemem POWER DEVICES
qm fli pp pe gLa
ty5O0 Matnmeraeensedpurerent70ardflevi,imumrs the Contractors License Law(Chapter
YyaC 9(eommeneing with Section 9000)o[DlvEirn 3nfthe Business and Rofessione Code) SWIMMING POOL ELECTRIC VALUATION
4%1 W or that he is exemp flarefromand the basis for the alleged exemption.Any violation of FIXTURES
F❑4 Section 7031.5 by any applicant for a permit subjects the applicant m u civil panalty of OUTLETS-SWITCHES-
❑yy not more than five hundred dollars($500). NEW RESIDENTIAL ELECfR SQ.PC. � L
IC m ❑ I,us ownerofinepmperty,ormyemployms withwagexas[heirsnlecompensmiof, STORIES TYPECONSTRUC ION
y 3.. will do the work,and the structure is not intended or offered became(Sea 9044,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work hlmselfor through his
ownemployeas,provided prolamin impoevemensafenm intended reoffered tarsale.If, I OCG GROUP RES.UNITS
however,the building orimprovenom is sold within one yeamfcompletion,theowner-
builder will have the burden of that he did not build or improve for se of TOTAL
builder
proving p puHw.
El
❑ Las nwmmonneproperty,am exert,aiveq romtmeingwhn ueenaca aomramorsm QTR. ' PLUMBING PERMIT ' " ' FEE FLooD zorvF nPN
Lnstruct the project(Sea 70,14,Business and Pmfiawlrns Cuba)The Contractor's
icense Law does not apply man owner of emp sry who builds or Improves Ramer,end PERMIT ISSUANCE
whocourraes mrsuchparects with a contractor(s)licensed pursuant to the Contractor's ALTER (EA)License Law. ) - FEESUMMARY
❑ 1 am exempt undersea. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby affirm that l have acertificare ofcousearto self-insure,oracedomase of FIXTURP.S-PP.R TRAP RECFI #
Worken'Compennvtirn lnnurvnea oro cenificd copy thereof(Sea 380!1,Lah CJ which PARK FEE Y N
ca,.ell employees undandra permit. GAS-F,A.SYSTEM-I INC.4OUTLETS RFC pU#
Policy# BUILDING DISION FEES
Company GAS-EA.SYSTEM-OVER 4 RVO PLANCHECK FEE
[j Candied copy is hereby funds hed.
❑ Certified copy is tiled tai@me city inspecninnd is Cf 6
GRCASG/INDUSTRL WASTE.INTERCEPTOR GRADING PEE
CERI'IFICA' -GF 7XE P� MWORKERS' GREASETRAP SOILS FEE
CO A 1 IN INSURANCE AA''
(Imssectionnaednm edit hepenniiismrnnehundmildellit l I SEWER-SANITARY-STORM EA.2W4T. ENERGY
in,less.) U``
I readily that in the path of the work for`vh ah thisperm nisi sued,+s I WATER HEALER W/V[i/ELECTR
not employ any pesos in as m V c te�i bject tSlhe Wr e PAID
Compensation Lawsor California. Dam sn rs WATER SYSTEMITREATING Tt Receipt#
NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
N (q become subject to the Workers Compensation provisions of the Latin,Code,you must
W ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING EE �s
a CONSTRUCTION LENDING AGENCY SEISMIC JFH `
UZ I hereby affirm thin here is a 000mmciion lending agency for the perfonnvneeof
Q the work for which this permit is i,oned(See.3099,Civ.C.) TOTAL: FLECTR FEE
Lender's Name
Leader s Add., - QTY MEQHANICAUPERMIT 'FEE'. ' PLUMBL u
I cut fy that I have read this application and state than the above information is
F W correct l agree to comply with all city and county ordinances and state laws relating to PERM)r ISSUANCE MECIIANICAL .
buildiag construnion,and hereby amhorize representodves oftbis city to ante upon the
Uabove-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TA
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against
liabi lities,juag entx,costs andexpenseswhich may in any way accrue against suid City AIR HANDLING UNIT(TO 10,000 CFM)
c of t� m ing of
AIR HANDLING UNIT(OVER 10,000 CPM)
Sigtare of pli.al/Comrramr 1)Date EXHAUST HOOD(W/DUC'
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT GO 100,000 BTI!) Data Recd #
Will me applicant or furore hupaiC de,C am store ear handle Berlina d Safety
an defined by the Cupertino Municipal Cale,Chnptu Alt,and ma flealO and Sefery HEATING UNIT(OVER I00,000 BTU) AAL
Gu1e,Section 32(aa
11 yea,
13 No VENTILATION FAN(SINGLF REBID)
NCEDA E
Will mm
eeppllevorfmBOILER-COMP(3HP OR 100,000 BTU) Ps AIVIA
urebullding occupant useeyuipmentordevices whichemit Ll
/ hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
DomatP �/ e71
NEW RESIDENTIAL MECT. JUN 2995
❑Yes El No H. SQ.FV
1 have read the hawrdoun materials requirements under Chapter 6.95 of the
Califomla Health&Safety Cody Sections 25505,25533 end C�lY 25534. 1 understand that V I ! OF Gjj f iL;pp�I�
if the building does not currently have a turning,,that it is my responsibility notify the f 1
ooccupant of the requirements which mus[be met prim to issuance of a Cerdficam of
ecuwncy. \�� �-
Owner or authorized agent Data 'f01 AL: ISSUED BY:
OFFICE