28303APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO'U11.DI G -ELECTRICAL
APPLICATION/PERMIT • PLUMBING L. -MECHANICA
BUILDING DIVISION BUILDING PROJEC1'IBENTIF'ICATION
PERMIT NO. O
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMfITALDATE
p/�
Ave 3AW L UNIT# LOT#
['wVj/1{+.s
OWNERSNAME: PHONE:
5 ` '
CONTR 'SNA LIC NO:
NIC
❑
CONTROL#
1727 7
ARCHI'ILCIFFOINEF.R:.IC NO:
1 LTL C sell
ADDRESS:
CONTACT: PHONE:
%Clh WA L'rL 61175-3y Il
Q1'Y. ELECTRIC PERMIT FEIi
BUILDING PERMIT INFO
BD ELECT PLUMB MECH
PERMIT ISSUANCE
❑ 11
LICENSED CONTRACTOR'S DECLARATION wi
1 hereby a
affirm that I am licensed under provisions of Chupmr 9 (commencing sh
gPP1.lANCES-RFSIDIl4T1AL
LOB DESCRIPTION
Section 7000)or Division Sof the Busineasand Prnmasions Cale, and myliceose is in
PANELS
fun force and effect.
License Class Lic.#
UPT02MAMPS
Data Contractor
201 - 1000 AMPS
ARCIIITECTS DECLARATION
1 understand my plans shall be used as public records.
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Poifiessimed
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm shat I um exempt from the Conmmoo. License law for the
TEMP. METER OR POLE INST.
following mason.(Section 7131.5, Business and Professions Coda: Any city or county
which requires a Permit to construct. aper, improve, demolish, or repair any stmemre
prompt its issuance, also requires the applicant forsuch Permit o file a signed statement
POWER DEVICES
that he is licensed pursuant o the provisions of the Contractor a License Law (Chapter
9(emnmencing with Section 9000)of Division 3nflhe Business and Prom,oions Code)
SWIMMING POOL ELECTRIC
VALUATION
to this he is exempt therefrom and the bssia for lhealleged exemption. Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant m a civil penalty of
OVTLEI'S- SWITCHPS- FIXTURES
not more than five hundred dollar, l$50(p.
❑ 1.wownemftlieprop rty,ormyemployeeswirhwagesuatheirsolecompensation,
NEW RESIDENTIAL ELF.CfR_SQ. FT.
STORIES
TYPE CONS'TRUCION
will do the work, end the venture isnot iniendcd nr offered for sale (Seo. 9040. Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and whoJoessuch work himselfar through his
own employees,provided that uchimpmvememsiumnot immnde icroffered outside. If,
OCC GROUP
RES. UNITS
TOTAL:
however, the buildingim imprevemens is sold within one year ofcompletion, theawner-
builder will have the burden of proving that he did act build or improve far purpose of
aale.).
$2 I, asownerofthe property, omeaclusively contracting with licensed contraction to
QTY. PLUMBING PERMIT FEE
FLOODZONE
MIN
consumer the projces (Sec. 7044, Business and Professions Code:) The Contractors
License Luwdoes nor apply munownemfprnpersy whobuilJsnrimpmves thereon, and
PERMIT ISSUANCE
whoeontmes forsuch projects witha mnomtoan) licensed Pursuant m Ihecomtscon a
License law.
ALTER- DRAIN&VHNT-WATER IRA)
FEE SUW IARY
❑ 1 nm exempt under Sea , B & P C for this mason
BACK FLOW PROTECT, DEVICE
SANITARY Ifir"Islu INIM pt,hS
N
LIPT#
SCHOOLTAX N
Owner Dale
DRAINS - FLOOR, ROOF,AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ I herebyaffirir this l have acerti0cmeofiamenve self -insure, macenificae etpl%TURES-1'Eft
sion losanceorocenof(Sec ifiedeopythereYou). Lab CJ which
Workers'Compcnsaur
covers.11 employee's under this permit.
Policy pB
TRAP
RECEIPT.
PARK FEE Y N
RECEIPT is
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
NGDIVISIONT•ES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PIANCII . _
❑ Certifiadeopyishembyfumimed.
GREASEBNDUSTRL WASTE INTERCEPTOR
OR 1
❑ Certified copy is filed widr rhe city impeninn division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SAS
COMPENSATION INSURANCE
SEWER -SANITARY -STORM FA. 200FT.
IN
(This section need not be completed ifthe Permit is for one hundred dollars (SIM)
or leas.)
WATER HEATER W/VENT/F.I.ECTR
I certify that in lbs perfamraace of she work for which this permit is issued. I shall
not employ any person in any mmner so as to become subject to the Workers'
PAID
Comperamionlalwsof C.lifomis. Data
WATER SYSTEM/IRRATING
m Receipt#
Applicant
NOTICE TO APPLICANT: IL after making this Cenificam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
became subjeerto the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pmmil shall he deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a conamiction lending agency for the performance of
she work for which this pesmil is issued(Sec.3099, Civ. C.)
TOTAL:
ELECTR IC FEE
Lender's Name
QTY. MECHANICAL PER T FEE
PLUMBING FEE
Lenda's Address
1 certify shat l have read this application and some that the above information is
correct. I agree to comply with all city and county ordinances andstam laws mixing to
PERMITISSUANCE
MECHANICAL. FEE
building construction, and hereby amhmiu representatives ofthis city to enter upon the
above-mentioned property, for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and ke��e'' amdess the City of CLINdim against
liabilides,judgmenta. costa and expo �hicS me my way ace artindant said City
AIR HA NO U(N 0.000C M)
AIR HA IT (OVER 10,
mean quen fthe gruntin is permrm.
EXHAUST H W U
PAID
Signakfe afAppli mV mrmm Data
HEATING UNIT(TO 100,000 ITU)
HA- DOUS MATERIALS DISCLOSURE
Date Receipt p
HEATING UNIT(OVER 100.000 BTU)
TOTAL:
Willsciciplicmt .,future building occupant atom or hamm hamar mmaterial
u defined by she Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(.)?
❑ Y. ❑ No
Wiil thcapplicanmrfumrebuilding mcupantuseequipmemmdcvices whichemit
haeardous air canlaminams as defined by the Buy Amu Air Quality Management
District?
❑ Yes ❑ No
I have read she h.mNous materials rcymoonams under Chapter 6.95 of the
Cade, Secs 25505, 25533 and 25534. 1 understand that
California Health & Safety Cadtion
if the building does not currently have. tenant, that it is my respensibiliOm notify the
BOILER -COMP(311P OR Ifq.IpO BTL)
ISSUAN AbT-0
LV/
au� 03
CII y - �S`�
�/- Lf a. �'(
BOILER - COME(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
occupant of the requirements which muss be met prior m issuance or a Ce0i0cme of
Occupancy.
ISSUED Y.
Owner or awherind ageat Data
TOTAL:
OFFICE