28158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
L
CUPERTINO - BUHDING-ELECTRICAL PERMIT NO. ^
APPLICATION/PERMIT PLUMBING-MECHANICAL L
NG DIVISION BUILDING PROJECT IDENTIFICATION DDRESS: SANITARYNO. AFI'LICATRINSUBMIITALDATE
ITN � I.OTM �ME P E CONTR TORSNAME: LIC NO:J&AYa 1- ISN/C CONfROLN
INEER: LI'N / ADDRFSS: ❑
cONTAT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
LDG ELECT PLUMB MICH
PERMIT ISSUANC1:
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRII IOF
OWp (hereby affirm that l am licensed under provisionsol'Chapher9(commencing with
❑100 Section 0007 of Division 3 of the Business and Professions Code,and my license is in PANELS
yam—j, full farcennd effect.
FZW License Class Li UPT02MAMPS
wQy Date ontmct 201-I(I00 AMPS
Z Ozrmsz AR TECTSD CLARATION OVER 1000 AMPS SQ.FI',FLOOR AREA gISQ.FT.
O'Z—❑ I understand my plan. tall be used sex blic records.
I:-N F_lsq SIGNS ELECTRICAL.
Licensed Promshom
OWNER-BUIIDER DE RATION SPECIAL CIRCUIT/MISC.
KOyE 1 berth y lirm that I am exempt liam th Ccular r'a License law for the
613-L followingr son.(Section 7U3 r'5.Bnsinese'ane Pn rasions Cale:Anycayofcoumy TEMP.METER OR POLE INST.
O G which re mea a permit m consmun,aM1eq impmve, emolish,oT repair any smumum
CE}� priorlui issuance,also requires the applicant for such nnivofleaslgnedamkenxim POWER DEVICES
m CMC) that he licensee pursuant to the provisions of the Con actor's License Law(Chapter SWIMMING POOL ELECTRIC
aio�e 9(cmm eneingwhM1Salian9000)of Diviaod3ofheB mesa end ProfexsionsCWe) VALUATION
W orlhut cisexempuhcrefromand cba' t . alleged emption.Anyviolmion of OUTLETS-SWITCHES-FI%TURFS
F_Z¢ Senior 7031.5 by any ap icum f, a it. othtall icannoacivil,mit f
55¢¢ not mo than five hull re dol y o
e'F-o ❑ L sown ofthc to m to eesw NEW RESIDENTIALELECIR _SQ.FT.
yon p y agesastcirsolec04.H.dron. STORIES TYPE CONSTRUCTION
will Pate and c .ctors Live n 1'wdoes not apply
to an owner
and Pro ssimrr W Contractors Lice a Law does sink apply m an owner of
properly r provestherean, hoarcnsLihwmkhroffer0nthmugn his
owncmr, ecsi) ordtbatsuars, i mnenthinne earocopletio ,thecdf.rones. OCCGROUP RES,UNITS
howevega ebuil oiiicrof that he did one year ofcompletion,for thcownen
hate.). anal a"ve`the burden of p Bing that he Jitl not build or improve for purpose of 1i
safe.).
❑ Laso erofthepro rty,amexclusively contracting with licensed emduaremsnr QTY. PLUMBING PERMIT FEE FLOOD ZONE AYN
amtru h the inject .70,14,Business and Professions Code:)The Commeter s
Liecose Law th-so apply to unownerofthoi who builds or improves thereon,and P17RMIT ISSUANCE
whoeartmepfr uchprojeetswilM1ucnntromoKs)Iicenxed pursmnlmkhe Contracmh ALTER- ( )
License Law. DRAIN EA FEE SUMMARY
❑ I nm exmnpl under Ser. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OU'1'SIDL FEES
OwnerDae SANITARY Y N
DRAINS FLOOR,ROOF,AREA,COND. RECEIPT N
-
WORKMAN COMPENSATION UECLARAT'ION SCHOOLTAX YN.
❑ Iherebyarfrmthak Llmveacor leen ofcopythersel6ave.38oracen.)whicf FIXTURES-PERTRAP RECEIPTN
Workers Compensaionder thus .i,.enified copy thereof(See.380,Lab CJwM1ich PARK FEE Y—N.
eove -
Pill,
all employee's under this pcnnik. GAS-EA.SYSTEM-1 INC.4 OUTLETS RBCEIPf N
Policy N BUILDING DIVISION FEES
Company
El CenilieJ opy is hereby famished.
GAS-EA.SYSTEMOVER4(EA, PLANCHECK FEE
c
❑ CenifeJ copy is fled with the city ins)wnion division. OREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FRE
COMPENSATION INSURANCE
This section need not becnmleted ifthe permit is for one hundred dollar,(SI00) SEWER-SANITARY-STORM EA.20Fll ENERGY FEE
in ess
I emify that in the erfommnce ofihe work for which his permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ any pnaon in any manner so as to become subject to the Workers' PAID
O z Cm.,ximatlunlawaof Califomm, Date WATER SYSTIDdI BEATING
Applicant Date Receipt#
z 0 NOTICE TO APPLICANT:If.after making this Cenificam or Exemption,you should NEW RESIDENTIAL PLOD. SQ.ET. TOTALsr V) become subject to the Worker's Compensation Provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING IEE
per- D
CONSTRUCTION LENDING AGENCY SEISMIC FEIi
Z I hereby affimt that is a construction lending agency for the performance of
V C) the work for which Nis Permit is issued(Scc.3097,Civ,C.) TOTAL: !FLER
Lender's Nume
0O U Lender's Address QTY. MEC `CAL PERMIT FEE EE
r Lal 1 certify thin L have mail Nis applinnion and state that the above information is
comes.l agree to comply with all city and county ordinances and slam laws relining to PERMITI SS NCE FEE
sn but Wing construction,and hereby authorixe representatives this city to enter upon the
U z above mentioned pmpeny for inspection purynses. ALTERO ADD TO MECH. ONTA%
I e)agree to save,indemnify and keep harmless the City of Cupertino against
fiabil'ms,juJgmcros,costs andestanses which may many way accrue against said City All H DLING UNIT(TO 10,000CF
eof the amingo 's pemni.
67 At ANDLINGUNIT(OVER 10.000GFM)
Slgr a Ap,luxrl/ omracmr am MUST HOOD(W/DUCq
kIA9AR0005 MATER( ISCLOSURE HEATING UNIT(TOL IB 11—
Will
ke Reevil.It
W ill the applicant or future building occupant store or handle hworammus material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT 0. TO)) TO
Code,Section 25532(a)?
❑Ye.s 0 N VENTILATION IF
( LE REST
I Will the upplicafuturebuildingereepant use equipment whichem BOILER- HPORI ,(qO BTU) ISSUANCE DATE
mor
hazardous air contaminants as detlned by the Bay Area Air Quality Mawgeme ROILLIF Y( VER IIXI, )
Uistria? qq
PA
❑Yes ❑No NEW RESIDE MECH. SQ B N
1 hove read he haeurdous materials requirements under Chapter 6.95 or the /.� o
California 14"Ith&Safety CWP,Sections 25505,25533 and understand
25534. 1 that v 199
if the building does not currently have a lewok that it is my responsibility to unify the
CI'
upant of the requirements which must be nick prior of issuance ol'a Cenificate of y
Occupancy. Ur t,urr ,.
Owner ar amm�n.ee agent Date
TOTAL: ISSUED BY:
OFFICE