28012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 10fL531 G. ..NF.TRI.AL PERMITNO.
APPLICATION/PERMIT PLUMB NG.MECHANICAL n O O el
BUILDING DIVISION BUILDING PROJECT'IDENI'IFICA-1'10 Lo 1
BUILDING ADDRESS 1}� SANITARY NO. APPLICATION SUBMITTAL DATE
S1 U`# LOT# I
OWNERS NAME: dJ, PHONE: CONTRACTOR'S NAME: LIC NO: i
30
1F%^ isIV'IV.\ Q -f/1O N/C COMAOLM
-• RCI IITECf/ENGINEER: LTC NO: ADDRESS: (-fs' J� ❑
�V �
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDCy ELF❑Al ❑ ❑l PLUMB ME
PERMIT ISSUANCE ACJ( '
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB CRIPTTON
Ibrom liffimnhm l am licensed undttpnckiomsnfa.baT9(cwtmenc h,voth I"r.•O Q+r Is^,s h,t 1. 0,
PDSection7000)af Division 3nf the Business and Profcsslobs Code,and my license is in PANELS �f
y' Full force and efftt
a D co GP TO 200 AMPS Sl
License LIC,#
t,Qy Dam Elaxs Cantmcmr 201-IOW AMPS FT.FLOOR AREA S/SQ.1T.
Z8O 7� ARCHITECTS DECI.ARATION OVER I"AMPS Q
01 G 1 understand my plans shall be used as public records.
r y F J� SIGNS ELECTRICAL U Licensed Professional
OWNHR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XXOa 1 hereby affirm Nat I am exempt from the Contractor's License law for the
ul3 R y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
IS 0; which inquires a pemtit t.conswm, he,,improve,demolish,oT repair any m...one
uN]}af prior 1.its issuance,a6.requirt,meapplicant fimamh permi0o fit easi,W summam POWER DEVICES
W COp
that he is licensed pursuan to the provisions nfthb Contractor's License Law(Chapter
o.ao� 96cnmmencing with Section]fl(IlpnfDivisinnJofthe Business and Professions Code) SWIMMING M30L ELECTRIC
VALUATION
�
W=H or that he is exempt therefrom and the basis for the alleged exemption.Any violation of �( �/
� Y Section 703 IS by any applicant for u prumh objects the appl icaat ton civil penalty OUTLETS-SWITCHES-
of FXTURES 3%
Q� notmo¢than five hundred doll:us(S5W).G I,mownerofNe pe y.mmyemploymswithwagesmtheirsolecompcnmtian, NEWRISIDENTIALELECfk SQ.FT.
3ttp ❑ pro n STiNIf'S TYPE CONSTRUCTION
a will do the work.and the structure is not intended or offered forsale(Sec.70,14.Business
and Professions Cade:The Contraction's License taw does not apply to an owner of
pr.Pertywhobuildsorimprovestbeann,and whndoesanchwurk himselforthrnugh his
employees,proviJed Ndt suchimpmvemenuurenrn imendalor nfferN for svle.If, OCC.GRO P RES.UNITS
however,Ne buildingnr improvement is sold within oneyearofeompleli.n,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
side). QTY. PLUMBING PERMIT- FEE ROOD ZONE APN
consmi❑ has the pmjf Ne prop 70,14,Business
s s an Professions
h de:)The Conacmtsm
License the project(Sec.]M4,Business pa Professions Cale)The Contractor's PERMIT ISSUANCE
License Law does not apply mu now nerofpmpcny whored pods or improves Commetwes
who contracts for such pmj«toe with a contmnor(s)licensed pursuanuo the Commctory
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I ant exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICES .FEB,
SANITARY Y N
Owner Date RECEIPT p
• c DNAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑ l hembyaffinn that l have ecenificete ofoomant oself-insum,mraceniftc¢mo( RRCEIIT#
Workers Com FIXTURES-PER TRAP
Compensation lnsurnnce or. copy Nercof(Sec.3gW,lab CJwhich PARK FEE Y_N
ersallemplgqyy ''under rruB GAS.CA.SYSTEM.I INC.4 OUTLET'S RIiCH11T#
P.1. If L✓r✓ �e" r�.-d BUILDING DIVISION FEES
Compvny�•��aa�••nr'A7a1 nn../
❑ CeniOetic py is hereby fumisheJ. GAS CA.SYSTEM-OVBRO(I?n) PLANCHECK PEE
❑ Certified copy is filed with the city inspection division. G SFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SETRAP SOILS FEE
COMPENSATION INSURANCE
('Diisaectiooncenum be completed Blue permit isfornne handset ars(SHO) SEWR-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I really Nat in the perfn m ceoftheworkfmwhic obit is issued.I shall WATT HEAT}R WNLNT/ELECIR
not employ any person fr any m as
to oma subject In the Wnrken.' PAID
Compensationlawsof Califomis. Dam sn W 3 YSTFAITRHATING pale Receipt#
O z Applicant
z 0. NO'T'ICE TO APPLICANT II',after making this Ce Icme.facibIdio .S!DENTIAL PI.MB. SQ.IT. TOTAL:
Fir become subject to the Workers Compensation pmvisk of NCLabmrC o s
� , forthwith enmply with such provisions.,,his pe.fish 11 Teemed . BUILDING FEE
W z CONSTRUCTION LENDING A G (/'��� SEISMIC FEE
IICJJ Ihereby affirm that there is a construction lending a e thep�c-till of
U O Ne work far which this permit is issued(S«.J09],Civ. J "VV TOTAL: ELECTRIC FEE
Iendcr'sNmtm s PLUMBING FF.R
0U Leadefx Address -TY, MECHANICAL PERMIT FEE
V 1 ceni fy that I have read this application and state t the above infomtmian i
>t W correct.I al to comply with all city and county ordinan and state laws bell id a PERMITISSUANCE MBCHANICALFEE
E" buil ding consruction,and hereby vcthmi,c tetsm,,nmtives Rhiscitylocnterup the
V z above-memiomed property for inspection purposes. ALTIiRORADDTOMECH. CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless the City of Cupeni against
liuhilllies,judgmend,cosrsvndcxpmues which may innnyw yacumeagai tamd City AIR HANDLING UNIT(TO 10,0010CF1,)
in consequence of the granting of Nis permit.
AIR HANDLING UNIT(OVER 10,"CFM)
Signature of Applicant/Cmmmntm Data EXIIAUSTHOOD(WNUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO I00,000BTU) Dote Rcceipt#
Will the applicant or future building occupant store or handle hveardous material HEATING UNIT(OVER 100.000 BTU)
as Acfned by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Calc,Section 25532(e)]
0Yes 13 No VENTILATION PAN(SINGLE RESID)
Will the applicant or future building occupant use equipmcmordevices which emit BOILER.COMP(31If'OR 100,000 BI Of ISSUANCE DATE
• haair comaminanrs as dcGne4 by the Bay Arta Air Quality Managemrnl BOILER-COMP(OVER 100,000 BTU)
Dlshict?trim]
❑Yet 1-1No NEW RESIDENTIAL MECH. SQ.IFI'. P A 6 D
I have Feud the husardous m dentis mr,mmmemts under Ch tTic,695 of the
Califomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand Nat SEP 27 1995
Bite building does noceureently have a tenant,that it is my responsibility to notify me
occupant of the requlrcmeme which:oust b,met prior to issuance of a Cenifieam of
Occupancy. CI I I UI"
Garci or mnharived agent Dme TOTAL: ISSUED BY:
OFFICE