28111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - - PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT " PLUMBING.MECHANICAL. !�8 1
BUILDING PROJECT IDENTIFICATION G o
11
BUILDING ADDRESS: �• SANITARYNO. APPLICATION SUBMITTAL DATE
4C / C ' 1/ UNIT# IAT#
NERS NAML: PHONE: CONTRACfOR'SN LIC NO: F
- N/C CONTROL#
�r
ARC
LIC LIC NO: ADDRESS: ❑
: N CONFACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
.RLDO ELECT PLUMB MUCH
PERMIT ISSUANCE col 1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALQMZ
FJ0C Ihuehyafflrmision air,3.rhe B uinssand isionsi Chapter and bactu
encingwith
in �rrr L
u]00 Section 7000)of Division 3o[thc Business and Professions Gde,aria mylioense ism PANELS `y'J
k., qwF full force and effect 44 UP TO 200 AMPS V VV License Claxs Lia.#
yy�
y Q y Data Gemlafmf 201-10011 AMPS - SQ.IT,FLOOR AREA $/SQ.UT.
2Or, ARCHITECTS DECLARATION OVER 1000 AMPS
O Z—t] -I understand my plans shall be used as public rec.Ms.
i,'w W SIGNS ELECfRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
C) U I hereby affirm that I am exempt from the Commetars License Law far the ,
It]�:Om following reasan.(Section 70315,Business rend Professions Cale:Any city or county TEMP.METER OR POLE INST.
.U...yrs] which requires a permit m cousvuct,alter,improve,demolish.or repair any Structure
`� Y� prior to its issuance,also requires the appicnntfor such permit to file asigned statement POWER DEVICES
W[y�p0 that he is licensed par........Wepmvlel.ns.[the Contractor',License Laws(Chapter
'4Wo 9(commencing with Section 7000)of Division 3 ofthe Business it Professions Cole) SWIMMING POOL ELECTRIC - VALUATION
W—, mNot he is exempt thercfromand the basis for the alleged exemption.Any violation of MOUTLETS-SWITCIfF.S-FI%T S
dnSection 7031.5 by any applieear fora perms subjects the applic.rl t...ivil penaltyof
t mora than five hundred dollars($500).p ❑ 1,asowner.ftheproperty,ormyctnpl.yeeswi0 wages aspheirsolecompensmi.n, NEW RESIDENTIAL P.LELT S .PT. STORIES TYPE CONSTRUCTION
W willdothework,andthesvueureisnot inrendulorOffered f.rsa,(Sec.]044,Business - _
and Professions Code:The Contractors License Law does not apply to an owner of
prepery who builds orimpfdves commit.and whadoes such workhimselforthroughhis -
own employees,pmvideJ thats.ch improvcmcneamum Intended or.ffemxl f.rsale.If, OCC.GROUP RCS.UNITS
however,the building or improvement is sold wihhir one yearref comphood,the owner- O'I'AL
builder will have the burden misusing that he did not build or improve for purpose of
ante).
❑ I,as owearmthepropeny,am exclusively contracting with licersul contractors to QTY. PLUMBING PERMIT . FLOOD ZONE AIN
construct the project(Sec.7W4.Business and Profession,Code:)TTo Convactor,
License Law does noloPply to an.wner.fpmperty who builds orimpraves thereon,and PERMIT ISSUANCE
who mnvacts for such projects with amntrialm(s)licensed pursuummthc C.norecfor,
lcense Law. ALTER (EA
) FEE SUMMARY
❑ 1 am exempt underSec. ,B&P C for this person BACK FLOW PROTECT.DEVICE UTSIDE.I•EGS
SANITARY YN
Owner Dale RF(7EIPT#
COND
AREA,, .
WORKMAN COMPENSATION DECLARATIONDRAINS-FLOOR, SCHOOLTAX Y - N
CIIh,eby affirm th.tlhnveeoertificnha of consem to eelGinsure,or a•cerpificidem - - RECEIPT#
"
Workers'Compensation lnsurtaceoracertificd copy thereof(Sec.3900,Lab CJFIXTURES-PER TRAP which PARK FEE YN
versnll employee's umderthisperch. _ RECRIPT# -
GAS-EA.SYSTEM-1 INC.40UTLETS
Polity# BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM-OVER 4EA) PLANCHECK FEE
❑ Cerlfed copy is hereby hammered.
❑ Cerilied copy is Bled with the city inspection division. GREeiSE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Gpd,,capia.need not In completed ifthe permit is for care hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
unless.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER I IEATER W/VENT/ELECTR
not employ any person In any mann,so us t.become subject,.the Wmka. PAID
Compensation Lows of C.lifvird, Date WATER SYS"TEM/TREATING Data Receipt
O z Applicant -
z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should N EW RESIDENTIAL PLMIL SQ.Fp, TOTAL:
F' fn become subject 1.the Workers Compensation provision,of the Labor Code,you must
forthwith comply with such frowisiors or this permit shall be deemed revoked. BUILDING FEE
W [] CONSTRUCTION LENDING AGENCY - SEISMIC FEE.
F 7 I herebyaffimunlen
lmhere is a c.nstrneJ.n ding agency far the performance of
U the work for which this permit is issued(Sce.3097,Civ.C.) TOTAL: ELECTRIC FEE
w Lender's Name
Ot-' Leaded,Address - QTY, MECHANICAL PERMIT FEE PLUMBING FEE
V I certify that 1 have read this application and slam that rhoabove information is
ct.
t7" LTa correI agew m comply with all city andenunty ordinances unilstaiel.staled..,t. PERMIT ISSUANCE MECHANICAL FEE
building c,amb.clon,tad hereby mahmi,eerepresenmtivesmin,eity,..mer uponthe - CONSTRUCTION TAX
V Z above-mentioned property for inspection fraii ex. ALTER OR ADD TO MECI I.
(We)agree to save,Indemnify and keep scales the City of r�(ltLL¢��aiXb
Iiabiliries,judgments,coasd expenses whlcharanyway are�c n
.ncn s AIR HANDLING UNIT IT 010.1100 CFM)
in consequence of the lr.ntin S permit. \�Jl - - -
a IRHANDLING UNIT(OVER 10,000 CPM)
nae� EXHAUST HOOD(W/DUCID PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will[lie applicant or future building occupied spire or handle hazardous material HEATING UNIT(OVER 100,0(10 BTU) O'
as dent
ed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? -
❑Yes ❑No - VENTILATION FAN(SINGLE RISID) -
BOILER COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Width epplieonmrfuturebuibingomupam.sectimpmentordeviees which emit - P rs ;
Side, air .a not,as dafined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 4 D
nstrt - .
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,IT.
I have read the hazardous'materials requirements under Chapter 6.95 of the �Y�2
C.1ifomi.Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that lx !t ✓N7
`t\
Fire building does not currently have a rental,that it is my responsibility to notify the
occupant of the requirements which must he met prior,.issuance of a Ce tiFene of
\ccupancy.
•er or uuflmrizad agent Date TOTAL: ISSUED RY:
OFFICE