28187 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ILEC I RICAL PERMII'NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICAT'ION
BUILDING ADDRESS: SANITARY NO. APPPIACA11 SUBMIlTA1.DATE
UNI'Tx LOTp 1 wr1
OW i SNA E: PHONE: CONTE O '9 LIC NO: N/C CONTROL. YY��
ARCIIIIECP/INGINEER: I LIC NO: ADDRESS: ❑
FCO�A�: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B LECT PLUMB SUCH
PERMIT ISSUANCE ❑
Ldut,[a1iDCm,cdmdTOR'SDE .fClm,ION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
flinn tbm tem lieenxedundapmvisionsofChvpmr9(commencing with0ofDiskint 3 of the Business and Professions Code,and my license is in PANELS
<Z, rrcd,¢ylyLiak UPTO2WAMPS
yCmnlmclnr 201-10X1 AMPS
ZQN'L ARCHITECTS DECLARATION OVER IIN)U AMPS SQ,FT.FLOOR AREA $/SQ.IT.
0 Z—D I undcrstnnA my plans shall be used as public records. O
ratw SIGNS ELECTRICAL A�
¢+L7j Licensed Professional (�J�
OWNER-BUILDER DECLARATION SPECIAL CIRCUEOMISC.
xC)W, I hereby indoor that I am"script from the Contractor's License Law for the
W 3 a vhas following reason.(Section 7031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INST.
F u O.] which reyuires a Permit m scone,cher,improve,demolish,or repair any in ucmm
,WY$ prior to its issuance.also)requires the applicant forsuch permit o file a signed nammend POWER DEVICES
,M<o O Net he is rceascd pursuant to the provision:of the Commences License Law(Chapter
1L ed 9 c with Section l")of Division 3 ofthe Business and professions Code SWIMMING POOL ELECTRIC
Kett (commencing ) VALUATI
W_w othat heisesempnhempom and the basPermit
ects me
dexemantto civiny 1preally of OUTLETS-SWITCHES-FIXTURES
FFJ- Sadiane than by anyapplicant for$pemtit subjects Ne applicant toacivil penalty of
W ¢ not more than dve hundred dollars(E500).
CI
F. ❑ I,esowneroftheproNM,ormyemployceswilAwagesastheirsolecompensatiun, NEW RESIDENTIAL ELECR SQ.FT. STORIES TYPE CONSTRUCTION
W Wet will do the work.and the structure is not intended orofrercd for sale(Sw.'/INd.Business
and Professions Code:The Contractor'a License law does not apply In an owner of
propeny who buildsorimproses lhercon,and whodews such work M1imedfarthraughbis
own employces.pmvided that such imprsearnms interval intended arofPored for sale.If, I OCC.GROUP RES.UNITS
however,the building or impravemcal is sold within one yeafof complctlon,the owner- TorTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
sole.),
❑ Las owner of life property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE? FLOOD ZONE APN
momacl the Prided(Sin.9011,Business and Professions Code:) [Is Connector'sLicense Law docs not apply to an ownerofpropeny,whobuildsorimproves thereon.and PERMIT ISSUANCE
who contmets hasuch projects with acontractor(s)licensed pursuaouo the Contractor's
License Law. ALTER IEA
) FEE SUMMARY
❑ 1 am exempt under Sin. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y—N
—
Date Date RECEIPT.
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX N
❑ Ihcrcby affirm lhatl have eccnificate ofconsenuoself-insure,orattnificam of FIXTURES-PER TRAP CEIPf
WorkersCompensation Insurance or accounts]copy theredf(See.3800.Lab CJ which PARK FEE N
rs ellemployee'a unAenhis permit CAS-EA.SYSTEM-1 INC. OUTLETS EI x
Polcyp B'LDING DI O -ES
Company GAS-EA.SYSTEM-OVER 1(EA) PLANCHECK
ElCenifie l copy is hereley furnished.
❑ Certified copy is GIN wilM1 the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING
CER 11] OF EXEMPTION FROM WORKERS' GREASEIRAP SOILS
COMPENSATION INSURANCE
This section need not M completed'like permit is for one hundred dollars($Ig) SEWER-SANITARY-STORM EA.201 ENERG
Un
odes.+.)
I cenify that in the performance of the work for which thispproul is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any ma +n as to become.+object In the Workers PAID
z Compcnsmion Lnweol'C.1maria. Date WATER SYSTEMTREATING Dat Rccciptx
nWbea a
zO NOTICE 10 APPLICANT:If.after making this Crofiewcof F:xempdion,you should NEW RESIDENTIAL PLMB. SQ.M. TOTAL:
F' y become subject o the Worker's Compensation provisions of the Labor Code,you must
forthwilM1 comply with such provisions or this permit shall be clamed revoked. BUILDING
d cONmUCfION LENDING AGENCY SEISMIC FEE Of
z I hereby affirm that there is a conawction lending agency for the performance of
U O the work for which this permit is issued(Sas 3099,Ci,C.) TOTAL: ELECTRIC FEE
Lender's Name
0 w
F Leers Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
U 1 certify that 1 have mad this a,licmion and state Nal be above information is
>- MECHANICAL FEE
CL.
correct. lugs mcomply with all city and emumy ordinances and smm laws relining to PERMIT ISSUANCE
F" (Z) building construction,fund hereby shimmies representatives of Nis city lecher upon the CONS'IRUta'ION TAX
U Z above-mentioned propcny for inspection purposes. ALTERORADDTOMECH.
(We)agree m save,indemnify and kap hmmlcss the City of Cupertino against
Imbilities.judgmentecnstsand expentts which may in any way. uui1, AIR HANDLING UNIT OI I M)
in onsrqu •of tM1e ming of this
AIR HANDLING UN (O IO.didi 'M
ANyAmrprrfApdnvmfVCom..mr qilie, j ExHA H DCT)
PAID
HAZARDOUS MAI[RIALS DISCLOSURE HEATI (To 100. U' Date Receipt x
Will lhcupplicunl nr Yuan,holding occupant score of handle baeanlousmmcrhd ❑IiATINGU (OVF,R 10 , BTUj '1'Ol'AL:
as defined by the Cupcolno Municipal Cade.Chapter A 12,and the Health and Safety
Cnlc,Staff n i 25532(x)1
C1 ye" 0N I
VENTILATION FAN(SINGLE RESID)
Will the applicant onaminants as
by the ay Area Air ualitycesanagemech nt
BOILER-COMP(3HP OR 100.00)BTU) ISSUANCE DATE
Pismo?s air contaminants as def net by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P$ A P
DindcRID
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. M 2
1 have read the hmmdous materials requirements under aspect 6.95 of the "— 995
California Health&Safety Cale,Sections 25505,25533 and 25531. 1 understand that w'•
if the building docs not choseny base a henand.Nal it is my respmisibilily to notify the
Rupant of the reyuircmendx which man be seed prim do issuance of a Cenidcam of CO ear
oancy.
Owner or mthsnieed agent Dam TOTAL:I I ISSUED BY:
OFFICE