28307 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMI'TNO. 28307�� O
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
1 BUILDING ADDRESS: w o CoI ,n SANITARY NO. APPLICATIONSUBMITTALDATE
Z I W l ( 5 r 4 UNIT LO'r» 11
WOOv�ER.gNAMg: PHONH: C'? rRALTOR'S NAME: ,, vs - LIC Nc;'L 3.^
Kd bGry— /✓�gP1dW 2Y3 �7r "3 u V rv/c coNTROL»
RCHTIECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG FILFCT PLUM
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑CZ I hereby infirm that am recruit under,mdxmrsofChapter9(Commencing with LOB CRIPTI
FJO2 Section 7000)of Division 3 oftheBusiness and Professions Cade,and my license is in PANELS
FFy�F fullf^rcevid < 30 3524 3J UPTO200
aZVj+l Lireme Class Lot. AMPS
ti a a Date Con 201 201-1000 AMPS
Fy" ARCHITECPSDECLARATIOT� SQ.FT.FLOOR AREA 5/ .FT.
1 ZOrn� �VIC OVER ELECTRIC
O Z.-
-p 1 understand my plans shall be used as public recoms.
ti�M SIGNS ELECTRICAL
W Licensed Professional
y 1< OWNER-BUILDER DECLARATION l SPECIAL CIRCUIT/MISC. SIC
KOn.F 1 hereby alfimr that 1 am exempt from the Contractor's License Law for the
W3tr-w following reaso^.(Section"/031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,after,impmva,demolish,m repair any svaaare POWER DEVICES
}� prior to its issuancyalsm requirestrair icam fmsach permiturfarld,nWslammm
e
y1 O0 that he is licensed platinum to the Provisions of the Contractor's License law lChapter SWIMMING POOL ELECTRIC
9(tormenting with Section 7")of Division 3 of the Business and Profennions Code) VALUATION
r^y
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Lz3 Section 7031.5 by any aPplountfor a permit subjects the appticanrto a civil penalty of
not tome lhaa five hundred dollars(5500). NEW RESIDENTIAL FlECTR S .PT.
❑ Lasowneroftheproperty,ormyemplO mswithwages esdairsolecompensation, Q STORIES 9YPECONSTRUCOON
a will do Ole work.and the structure is not intended mr Offered fmsale(Sec.7044,Business
and Professions Cale:The Carmichael License Law does not apply to an owner of
property whobuildsorimprovesthcxon,wd whod^essuch workhimselfmrthroughhis
employees,provided tM1atsuchimprovememsarenmtimendedmrOffered forsme.
If. OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofcompletion,the^wner.
builder will have the burden of that he did not build or int for f AI
provin6 prove purpose
sale.). QTY. PLUMBING PERMIT FEE ELOODZONE APN
❑ uct the pr ject(Sec.7 .an exclusively Professions
wish de:)Th eo ontrul m
Construct We project(Sec.loan
Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law doesna apply torn ownernfptoperty w eased puds mimpto the Concrn,a^d
License race fonuch projttHwith awnwctor(s)licensed pursuant the Conrrxmrs ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
License IoW.
❑ 1 an exempt under Sec. .H&P C for this moron BACK FLOW PROTECT.DEV ICE1 E FI.
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AR COND RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby offitm thetlheveeccrtifcete of mnsenno self-insure,ora certifcure of IXTURES-P TRAP RECEIPT»
Workers Cnmpensution Insurers oracenifiW copy thereof(Sce.38W,Lab C.)which PARK FEE Y N
rs IlewN�b a udn is 't GAS-EA.SYSTEM-I C.4OUTLETS RECEIPT],
Policy» N L BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER ) PLANCHECKHM
❑ CenifiW copy is hereby fumisheJ.
Cl Cemified copy is fled with the city inspection division. GREASEIINDUSTRL WASTE IN,91PI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAPSOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is forone hundred ollars(5100) SEWER'SANT STORSM ENERGY FEE
or Real
L certify that in the performance of Ne work for which this perm ishoued,lehml WATE E M T/;Kc IR
not employ any person in any nommer so M to her..subje to the Workers' PAID
Compensation Lawsof Califnmia. Dore 5 I Dam Rtteipt»
O Z Applicant
z O NOTICE TO APPLICANT:If,after making this Certificate of Exe tion,your NEW RESID LPLMB. Q.FT. TOTAL:
V) become subjcet to the Worker's Compensation provisions of the Lab^ odc,you must
1 f^nhwith comply with each prnviaionr nr this pemnit shall be deemed re ked. BUILDING FEE
[(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affinot flea hem is a Construction lending agency for the perfn of
L) O the work for which this pcmu,is issued(Sec.3097,Civ.C.) ELECTRIC FEF.
)r Lendef's Name
OV Leri Address dANI... PERMIT FEE PLUMBING FEE
I certify that 1 have read thin application and atom the the above infmmaden is MECHANICAL.FEE
coma.I me be comply witha11 city and...my ordinances and alone laws miming to PERMIT ISSUANCE
building construction,and hereby authorim tepresemutives Ofthis city menterupon the CONSTRUCf1ON TAX
V Z above-mentioned properly for inspection purposes. ALI ER OR ADD TO MECH.
(We)agree m ave,indemnify and keep hamless the City of Cupertino.,at.,
liabilities.jvdgmenis,coset lode penal hit.h may in any way aacccrue gainatsaid City AIR HANDLING UNIT ITO 10,000 CFM) r
in<onuyupn<e nt'tha gran thio penniL 751Cs
AIR HANDLING UNIT(OVER IO,Oro CFM)
Signaw of ApplicenUCommnm Dam EXIIAUST FOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,00 BTU) Date Receipt»
Will the the Carmine or ture Municipal Code,Cng emamreo.handaddleha:atainers rtand Safely HEATING UNIT(OVER 100,00],BTU) TOTAL:
ss defined by the Cupenim Municipal Coda,Chapter 9.12,and Ne Hca0h and Safety
Cade.Section 25332(e)?
0Yes ❑No VENTILATION PAN(SINGLE REBID)
Will Ne uammbuilding nrnmt BOILER-COMP CIffs OR 100,000 BTU) ISSUANCE
SSSUANCE D
ATE
hawdous air Contmmates in defned by te,Bay Amu Air Quality Management BOILER-COMP(OVER i W,000 BTU) rpBV
Dtsmctn NEW RESIDENTIALMECH. . .SQFT
❑Y. ❑No ,0
I have lead the h xardmus mmeri ils requirements under Chapter 6.95 of the C/� 198
California Hemth&Safety Cade.Sections 25505,25533 and 25534. 1 understand that
if the building does not Carmody have a tenant,that it is my responsibility to notify the h �UNtkl ry
occupant of the requirements which must be met prim to issuance of a Certificate of
. Occupancy.
Owner or authorized agent Date T ISSUED BW
OFFICE