28482 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMITNO. 28482
S
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BUILDING DIVISION APPLICATION/PERMIT PLUMB ING•MECHANICAL 8( 8 2
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL UNIT
OWNER'S NAM: PHONE: C'I�s '. NAME LIC
105 / (l N/C CON'T'ROL4
AR ITE G[WER: `� I.Iq Q I �Amok r S T7�J ❑
I �yi lj/)
CONTACT. PHONE: BUILDING PERMIT INFO
4x�� '(J/� n��/L_ ,�,,I ❑ Consultant Fees Paid by Applicant Ordflat) ELE PyD�er MECH_
LIC .ED CONTRAC9'OR'S DECLARATION jv Q Y ELECTRIC PERMIT FEE IDL67\•�*jJ[\•
I hereby aflinn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z wiNSecto.700,D)RIDivi' 3uOR Business and Pnf<ssinns Cnde,anJ mylicense is
DO n PERMIT ISSUANCE RESIDENTIAL: _
n full force and effect. /
V U�k3 Liceue C Lic. '- ❑SFDWI. ❑KITCHEN REMODEL
'��a Uase Convncun AI'i'LIANCF,S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
1-210 ARCHITECTS DECL ON PANELS ❑MULTIUNIT ❑STRUCTURAL
Z O V2 Z 1 undersmnd my Alam Nml he used m public records MODIFICATION
CZ-9 UP102MAMPS El INTERIOR ❑CHIMNEY REPAIR
gipF t(J E. Licensed Licensed Professional 201.1000AMPS IMPROVEMENT
fi ❑ OWNEm cUILDF.R UECLARA'I'ION
I hereby amrm Nat 1 em exempt from she Contractor's License Law for the OVER IBBOAMP$ ❑BATH REMODEIIREPAIR ❑DEMOLITION
OyU following reason,(Section 7031.5,Business and Professions Code:Any city or county SIGNS F.LF.CI'RICAL []OTHER3 W E' which requires a permit to construct,aber,improve,demolish,or repair tiny structure
prior to it issuance.at so require.ethe applicant for such permit to file,°signed statement SPECI AL Cl RCUTF/M PIC.
} That he is licensed pursuant o the provisions ofthc Contractor's Licese Law(Chapter 9
00 (commencing with Section 70f10)ofDivision Sof Ne Businessund Professions Code)or TEMP.METER OR POLE 1NST COMMERCIAL
a M C Net he is exempt therefrom and he basis for Nc alleges exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y• Section 7031.5 by any applicant far a permit subjects the applicant to civil penalty of POWER DEVICES
of Rom than five hundred dollars S50). 'NANT ❑FOODSERVICE
cal
❑1,ee ownerof the propmy,mmyemployea with wages us their solerompcnaasion, SWIMMING POOL ELECTRIC I PROVEMENT
pf will do Nework,andtheatuameisnot inrendedoroffesed farsalc(Sac.7(44,Business ❑OTHER
3 and Professions Code:The Cumremors License Law does nm apply m an oxner of (TILE-TS-SWITCHES-FIXTURES O
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements one ani intended or ollered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold within one ycarofcompletion,the SQ.Fr..FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that be did not build or improve for put. Seg
pose of trial. T016("
❑ 1,as owner of the properly, or exclustsely eummwing with licensed ormermrs u
cnnsuuct the project(Sec.7041,Business and Professions Cede:)The Contractor's Li.
ase Law does not apply to an owner ofpropeny who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who commcB for such projects with o coatrnamp)licensed pursuanno the Cimonemrr
License Law. PERMIT ISSUANCE
Iain exempt under yes. ,B&P C for thisrcrom
Owner Due
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 80
1 hereby°firm under Penalty of perjury one of the following declarations: Tq
E] I huveund will muinmin a CnnilicatemConscm to self-insure for Worker's Cotonou. DRAINS-FLOOR,ROOF,AREA,GOND' 5 TYPE CONSTRUCTION
nation,as provided for by Section 3700 of the Labor Code,for the performance of the ST0I
w rk for which this Pe rm it is issued FIXTURES-PER TRAP
I have and will oommain Worker's Compensation Insurance,as required by Section
3 Iof Ne Labor Code,for the performance ofthe work for which this permit is issued, GAS-EA.SYSTEM-)INC.40UMETS OCC,GROUP MIN
My We 1t5 nl �rn ar rand Policy nylp r /1��11A GAS-EA.SYSTEM-OVER -
Cortier. ��.rrsx{{aaO4FFxLIN No. W !� U-1
CERTIFlI CATI:OFLr%EMP ION IRAN WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
11
COMPENSAT 1NSURANCF. BUIL I DIV ION RTES
eminn need not hewmplamd if he permit is(name hundruWnllurs is l(a)
leas] GREASE TRAP
or
PLANCII[CK F
Loy any that in the any manner of the work for which this Permit rksst'Cm,enll SEWER-SANITARY-STORMEA.2fill
not employ any person in any manner u m m become subject m the Workers'Compen- ENERGN�E
Z sides,Laws of California.Date
O ' EATER WNENT/ELECTR
y � Applicum � GRAITNAE
q FN•t NOTICE TO APPLICANT:If,of r,making this Cerifiem,of Exemptimn u d WATER SYS REATING
W become subject to the Workers Compensation provisions of th ode,you must SOI
provisions forthwith comply with such .,,his permi S- revoked. WATER SERVICE
Q
CONSTIIUC'TIONI-IIN)1NGAGENCY NEWRESIDENTIA PLMB. SQ,PT. PAID
U0 Thereby nffinn ohm thereiaectnslmnin lending agency forme perfoa enf I DemLRc.i,lp
D. F the wmk for which Nis perosit is issued(Sec.3 7,Civ.C.
C) U Lenders Name TOTAL:
Leader's Address
6i I certify that I hove read Nis application a sit,
ov ioli) tion 4 BUILDING
V) correct.l agree m comply with all city and county Nimance. dams,law sun t.5 Y, .CHANICAL PP.RMIT FEE
U Z building construction.and hereby nuNonze represe tiss", hs, cirym o`er polOhe SEISMIC FEF.
F-t above-mentimned p,o,,,y for inspection Pit i_. 17RMITISSUANCE
(Wo)agree Into e,.indcnmify and keep hurts, ar Nc City of Cnpenino against ELECTRIC FP
liabilitics,judgmene,colo,ande.,inieswhichrunym ny wryaccmeagainst said Cr ALTER OR ADD TO All jMECHANICA
E
i.e.RIjqca.flh e Bmnsi -(this pesmid. kt
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PPLITI' ERST D. NO WI LCOMP. WITH ALL -POINT AIR HANDLING UNIT(TO 10,000 CFM)
G LAI If FEEytl� g.J'� AIR HANDLING UNIT(OVER 10,"CFM) TAX
S' ol'Applir C am C/ Data EXHAUST HOG)(W/)UCI) HOUSING MITI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicaw or future building occupied store or handle hazardous material HEATING UNIT('TO 11,ZTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety fh, -
Co le,Section 25532on? �I HEATING UNIT(OVER 100,100 BTU)
r]Yes yy No PAID.
J� VENTILATION FAN(SINGLE RESID) Q
Will Neu Meant or future building �S D° Receipt N
PP d by the
Are.
Air emot Mireawhint BOILER-COMP(3HP OR 1(X1,(100 BTU
emit hanurduus sir cnmemina`ms us Jcfinth by tlm Bay Ares,Air Quality Managemem ) y
DiunmO es RI No BOILER-COMP(OVER 100,000 BTU) o,� v 7 TOTAL:
I haveread the luccomus mumdals ncquiremoms under Christer 6.95 o1'me Cali- AIR CONDITIONER - - IS.UANC ATE
Torula Health&Safety Cale,Sections 25505,25533 and 25534.I understand Ned if the NEW RESIDENTIAL MECH. SQ.Pr
huilding dms row curcmly have o¢naps,Nat it is my responsibility m nrtify the cectpant
of the Requirements which must be met From to issuance of a Certificate of Occupmcy.
s
Owner or authorized agent - Date '1 IAL: ISSUED BY:
OFFICE