28419 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUIL D; G-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL nO /I (]
BUILDING PROJECT IURNTIFICATION G o 4 J
BUILDING ADDRESS: /C.{ SANITARY NO, APPLICATIONSUBMITfALDATE
ITN T. S3ot
OWNER NAME: PIIONE: CONTRACTOR'S NAME: LIC NO: 77
_ _ N/C CONTROL p
CHI'I.CT GINE+R: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG .LE PLU CH
PERMIT ISSUANCE El "EP
LICENSED CONTRACTOR'S DECLARATION gppl.lANCES-RESIDENTIAL ,rsO �SC
rsf
Met thereby affirmthat l amlmensedunderprovisionsafChapter9(commencing with 11r}''rvf/`-1[„ I'"'"II\Yp S—�`—(r��N'7/�-�J)
t$4,00Section]IXIO)ofDi " 33 ofthe Business 5and Pmfessionx Cade,end my licrnxis in PANELS
mW
L'clease and mi
20 Lic.N -3 0 14 "1 UPT02MAMPS
to<c. Date '^�,—'Z g—�+C' Contro _ 4K 201-1000 AMPS
FyZ ARCHITECfSD LARATION SQ.IT.FLOOR AREA $ .FT.
y0'°— Iunderstandm In hall be used as blit records. OVER IIXp AMPS
OZ^O YPa es public
r r3�; Licensed SIGNS ELECTRICAL
KQ Professional
OWNER-BUILDER DECLARATION ContT10N SPECIAL CIRCUIT/MISC.
ycVc.. 1 hereby mason.(Se thm I am exempt from the Cession ie License Law for the
W3�Lr which refure (Section 7031.5.Business and Profusions Code:Any city or county TEMP.METER OR POLL INST.
which requires issuance,permit m cores the epee improve,demolish,m repair any swment
pat heor toir lcenedpursers To the
thevisionsocant for thesuch Co permit's file a License
La statement POWER DEVICES
dKcK G 0 That he is licensed p Sectio m the).Di is of the Contractor's License Lew(Chapter
�' 9(cnmmeneing with Scaion]OIXq of Divieinn3ofthe Business end Pnftssiov Cade) SWIMMING POOL ELECTRIC VALUATION
ITT o, or thin he is exemptthercfmm and the basis loathe alleged exemption.Aayviolation of OU'D.ITS-SWITCIIF.S-FIXTURES
E y< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nm mare than five hundred dollen(5500). NEW RESIDENTIAL ELECIR —SQ.PT.
❑ hesownefofthepmpmy,ormymSd.yeaswhhwagesasdad,olecompennatioa, STORIES TYPECONSTRUCfION
a3— will do omwork.anJ the structure isnot intended or offered Income(see.7DUI.Business
and Prussians Cole:The Cantmctals License Law does not apply to an owner of
propmywhabaiIdsor improves thereon,andwhodoessuchwork himesu forthroughhis
ownemployces.WovidedffiatsuchimpmvmmcsarenotintendedoroffertdfmWe.If. OCC.GROUP RES.UNITS
It the building mimprovemeat is sold within one year Ofmantletite,the owns TOT L.
builder will have the burden of proving than be did not build or improve for purpom of
s le.). QTY. PLUMBING PERMIT FEE FLOOD ZONE "N
❑ I,ct rofshe Sec.7 y ,Business
and ntmciProfessions
wilt de:)The Contractors
rs
construct the as(Sec. om o Business and Professions Code:)The Comncta d
whocelats for otopplymanownerofpmpnty whobuildsorirm come thmormara PERMIT ISSUANCE
whoro Law. orsuch projeclswithomnuector(s)littnsedpureuunuahe Contmctofr A RAIN&VENT-WATER(PA)
License Law. FEESUMMARY
❑ I um exempt under Sec, ,B&P C fm this naso BACK FLOW PR CT.DEVICE OUT SIDE RIES
SANITARY Y N
Owner Dem DRAINS-FLOOR,R F,AREA, D. RECEIPT#
WORrO
KMAN COMPENSATION DECLARATIO SCHOOL TAX Y N_
❑ Ihemby effrm thm lhavencenilicmc of conumTo self= rc,orecmifiwte of FI%TURES-PER TRAP RF.CI3IITp
Workers Comlmnsarinn Insurance Oaacenified copy th (Sec.3800,Lab C.)which PARK FEE YN_
coversy all employee's under this pemtif GAS-BA.SYSTEM-I INC. OUTLETS
RECEIPT Is
Policy BUILDING DIVISION FEES
Compan GAS-EA.SYSTEM-OVE (\A) PLANCHECK FEE
nified copy is hereby fumishW.
CaniEW copy is filed with the city inspection diet'on. EASF./INDUST IN .RCEPT'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' GREASE SOILS PEE
COMPENSATION INSUR INC,
(Thissecrion need natbe camplemd if the per mitis Toro ehun doll ( S R- ITARY-ST MEA.2(IOFT. ENERGY FEE
as less.)
I amity that in the performance of the work for which this ed,I shat A HEATERW /ELECIR
not employ any person in any manner eco as to hecome su 'act n Workers PAID
Compammion Lawsof Cilifomie. Dam WATER SYSTE BATING Data Receipt#
Z Applicant
z C NOTICE TO APPLICANT:It,after making this Cerificare of Exe Tormyoushoold NEW REST AL PLMB. SQ.Ff. TOTAL:
(q become subjea'sthe Worker's Compensation pmvisiona of the La Cale,youmust
forthwith comply with such provision<or this permit shall bedttme eked. BUILDING FEE
G (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
. z I hereby affirm Thar share is a construction lending agency for the ce of11 TOTAL: ELECTRIC FEE
V O the work for which this permit Is Issued(Sec.3097,Civ.C,)
E
Lender's Name
�^ Under',Address QTY. MECHANICAL PERMIT FEE PLUMBING FF,I,
W 1 cenify that 1 have mad this application and state that the above information is MECHANICAL FEE
CII Correa.l agree to comply with all city and county oNinsrmattid male laws rtlming to PERMITISSUANCE
y buildingconstrvction,and hereby tommom mprcsematives oflhis city menter upon the CONSTRUCTION TAX
V 7 above-mention A propmy for inspection purposes. ALTER OR ADD TO MECH.
r7 (We)agree to save,indemnify and keep hmmless the City of Cupertino against
Iimiliies.judgment,cosu and expenses which may in any wayacermagaimt said CityAIR HANDLING UNIT(TO 10,0011 CFM)
in consequence of the grunting of this pe.ir.
AIR HANDLING UNIT(OVER I0,00o CFM)
Signature of ApplicanVCOntmaor Da¢ EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100M BTI) Date Receipt IT
Will the the Cuantorf,ture Manic&Cnale,Cmentiantmorc o,hanand to Hash us and Safety
HEATING UNIT(OVER IOg000 BTU) TOTAL:
al
as define)by the Cupertino Municiyypaaf��CCCode.Chapter 9.12,end the Health end Safety
Code,Section 25532(a)] / VENTILATION FAN(SINGLE RISID)
❑Yes �y
BOILER-COMP(3HP OR TOT,"T,"BTU) f�I�gSSUANCE DATE
lme,ai applicantorfummbuilangmcupenBayat ens Aint Quality
Management
r A i D
hsaardous air contaminants u nes by the Bay Arae Air Quality Managemem BOILER-COMP(OVER 100.000 FIT U) PY IIi
Dimbet^ 9
❑Yes No NEW RESIDENTIAL MECH. SQ.Ff. JUL 2Z 19
1 have read the Safety
Code,
materials requirements under Chapter understand
of the
if the building
ing lthdo&Safety Cade.Sections 255115,25533 and responsibility
I undersoM that C�I Y
campoou ofIjdoesact currently
ncresw ihave a chorrcnanLthmitismymspouibilitymnotifythe V Ur VUrt„II
oecu�'of =quiremen us et prier m i once of�a yCe�n#iEram(o�f
(kcu !flG X2I—'is
Owne authonxed agent Dam L ISSUED BY:
OFFICE