28149 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 UJIMING-F:LF:CTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 28149
] O a� A4 J(]
BUILDING PROJKCIADEN'1'IFICATION L o 1
BUIIL�y•DIING�GAAD�IDRRESS: �s SANI'T'ARY NO. A/IPPLICA9'ION SU�B/MIE:
`ITAL DAT
✓ ✓ y O • LOTH
OWNS NAME: PHONE: I'RACTOR'SNA . LIC NO: ��! J
3 N/C CONTROL#
AkCHITECI'/ GINF.FR. LIC O: ADDR 'S: ❑
CONTACT: PHONE: ISUILDING PERMIT INFO
QTY, ELIiCTRIC PERMIT FIRM
BLDG ELECT PLUMB MECH
ate 2m PERMIT ISSUANCE 0
LICENS17D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBD �IO�N
OfYZ IeambyafOrm theU em licensed unrerpmvisions of Chepter9(cammencingwith �
u00 Section 70)Bmf Division Sof the Bmine,a and Pmfcssions Cale,end my license is in PANELS
FY� fullme Clndeffect.
FZ,� License Class Lic.p UP T0200 AMPS
oi, Dam Contmeto, 201-1000 AMPS
Z8y4 ARCHITECTS DECLARATION OVER 10110AMPS SQ.FT.FLOOR ARRA SISQ.FT.
0 Z-" 1 understand my plant shell b,used as public retards.
F rn E q SIGNS ELECTRICAL
Qx 7..I I.menxd rroreaai.nm
C6 OWNER-BUILDER DECLARATION SPIiCIAL CIRCUIT/MISC.
f m the OyF I hereby orthat 1 aexempt Tran Connector's lAnyc law for the
W�Oy
following.im'. (.ittn7U3L&Business and Professions Co de:Any city orcounty TEMP.MCTER OR POLEMST.
caFz.; < whithitsiisuan permit maimstealter,improve,demolish,orrepair anyewctum
X'e>� Prieto its issuance,also reyaires the eppliwmfor such permino fileasigned emtement I'OWF.R DEVICES
co 00 that he is licensed pursuan to the powisionsofthe Comma 's License Us.(C)apter SWIMMING POOL ELECTRIC
9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) VALUATION
or that he is exempt herefromand the Nois for iheolleged exemption.Anyviolati.nof OUTLETS-SWITCHES-PIXTl1RES
F.7a¢ Section 7031.5 by anyapplicent for.permit subjects thcapplicunth,a civil penalty of
net mom than five hundred dollars(S500),
C� ❑ hmawnendthepmpeny,ormyemployeeswithwegeamtheirsomecompensmion, NEW RPSIDFNTIALELECHt _SQ.FT. STORIES T'YPECONS'1RUCTION
3., will do the work,andthemumurc isnot humdednrnffcred fwsame(Sec.7044,Business
and Professions Code:The Contractors License Law dws not apply to an owner of
propcnywhobudds orimproves thermn.and whodocssuch work himselforthroughhis OCC CROUP RES.UNITS
nemployees.pmvidcd thatsuchimprovemenuere not intemadmoffercd for sale.If,
however,the building orimprovement issold within one yearol'completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
stic.).
❑ 1,as Ownerof the property,ameaclusivelycomracting with licensed cormuchrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cnnstmct the project(Sec.7094,Business and Professions Code:)The Contractor's PERMITISSUANCE
Licensel.awdnes mol upplyto m ownernfpmpeny who builds.,imreo
proves thereon, it
whocommem for such projmts with itemlaction)licensed Pumuanrtothe Contraao's se Law. T
License
pLTIiR-DRAIN&VEN -WATTR(EA) FEE SUMMARY
❑ i am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DRVICI? O ,IDE F.
SANITARY Y N
Owner Dam RRCEIPTM
DRAINS-FLOOR,ROOF,ARFA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL T'AX Y N
❑ Thereby affirm thatlhavencenifiwfe of consent to self-insure,oraxnifcatanf RI1C1i1P1'p
IlXT1IRIiS-PER TRAP
Workers Compensation lnsumnce oar cenifiedc�py thercoflSec.3X!10,Lah C.)which PARK LEE Y N
coven Ill employer's under this Front. GAS-EA.SYSTEM.I INC.4 OUTLETS RECI;IPT p
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 BA) PLANCHECK FEE
❑ Certified copy,is hereby famished.
❑ Cmified copy is fled with the city inspeninn division. OREASHANDUSTRL WAS TE INTERCEPTOR GRADING FEE
CERT'IFICAT'E OF RXLMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This scclummed net be completed if Ne permit is forum hundred dollars(SIDO) SEWER-SANT PARY-STORM FA.200ET. ENERGY FEE
or leas.)
I cenify that in the p:rfrrim,rof Ne work for which thispermit is issued,)shall WATER HEATER W/VENI'/ELLCfR
not employ any person in any m es no become subject to the Workers PAID
z Compensolion Lawsof California. Date xo WA'I'L'R SYST'EM/IRFATENG Dae Receipt If
O O Applicant
Piano!10 APPLICANT:ITL after making this Certificate of Exemption,you should NEW RESIDENTIAL FUME, SQ.FT. TOTAL: /
4 hecnme subject o the Worker's Comperemom provisions of the Lubar Code,you must
a ; forthwith comply wi nh such pmvi cions or this perrot shall he deemed revoked. BUILDING FEE /
W
z CONSTRUCTION LENDING AGENCY S171SMIC FEE
✓R Ihereby affirm[hit( is a construction lending agency for the performance of
U O the work for which this pennin is issued(Sec.30x17,Civ.C.) TOTAL: ELECTRIC FEE /
4k. Elender's Nauru
PLUMPING ME /
O lender's Address QTY. MECHANICAL PERMIT FEE
T cenify ds.t I have read this application end store that the all information is /
correct.l agree no comply with all city and county ordinances and stere laws relating to PERMIT ISSUANCE MECHANICAL FEE
00 buildingconsmsction,and hereby sothnrize representatives ofthis city to enter upon the CONSTRUCOON TA% /
U 'z above-mentioned property for inspection puryoscs. ALTER OR ADD TO MECH. i
(We)it".to so* d keep harmless the City of Cupenina against
liabili'., em,c nndexpenseewn ay inany way acerueaEainst said City AIR HANDLING UNIT(TO 10,0(1(l
co re grana his p• /
...� AIR HANDLING UNIT(OVIiR 10.000 CLM)
Sign A canVContractnr
at. HXHAUSTHOOD(W/DUCD
PAID Y
IfAZARDOUS MATERIALS DISCLOSURP.
HEATING UNIT 1pfl,IXg1 BTU) Dam Receipt K'
Will the applicant or future building overlent store or handle humorous material IIPATING UNI'!(DVGR 100,00!1 BTU)
as defined by @c Cotonou Municipal Code,Chapter 9.12,and the Health.1 Safety
Coda Section 25532(x)7
0 Yes El No VENTIIATION PAN(SINGLE RESID)
A
Will the applicant or future nt building occupauueym uipmeordeBOILER-COMP SHP OR TIL"BTU) W IDSSUNCEDATE
em
viceswhich it �
hazm1l ah contaminant,as defined by the Bay A.Air Quality Management BOILER-COMP(OVER I00,E1W BTII)
it DismiI h r e
❑Yes 1-1 No NEW RESIDENTIAL MECH.-SQ.FT. lot
I hove reaA nhc hnzardoue m.mriuls requirements under Chaper 6.95 of theingdoaveatnt,thnitT�jUU)) G
ifthe building dors not currently haveamnem,that it is my responsibility tenuity the
Occuptm of Ore requirements which must is met prim no issuance of o Cenir¢am of V //
Ocnq+;mcy.
Owner m auNainsi agent hate TOTAL: 15SUED BY:
OFFICE