28232 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL
APPLICATIONIPERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO. 28232 L SIlJ L J1 A ^ A
L
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMTITALDATE
1v risl UNIT# LOT#
OWN SNAMR: PHONE:
CO ACTOR'S NAME: LIC NO;
707
CONTROL
ARCHI .0 NGIN R: LIC NO:
ADDRESS:��
❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby am th
ffirat l am licensed anderprovisim aofChap rr9 (commencing with
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
Section 7") of Division 3 of the Business and Professions Code, and my license is in
PANELS
Mine end if
License Clay, Lic.X 3493olo(o
UPT02MAMPS
Dale Contractor
201 AMPS '
ARCHITECTS DECLARATION
- 1000
SQ. FT. FLOOR AREA
$/SQ. PF.
OVER KIM AMPS
I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUODMISC.
I hereby affirm that 1 am exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professwas Code: Any city or county
which mcmir a permit to construct, mac improve, demolish, or repair any structure
POWER DEVICES
priorto itsisuence, also requires the applicant foruchpimitto file asigned statement
that he is licensed purauant to the provislom of the Contractor's License Law (Chapter
9(commencing with Section 7000) of Division 3of the Businexs and Professions Cade)
or that he is exempnbereffom.andfle basis for the alleged exemption. Any violation of
Section 7031.5 by any applicmn for a permit subjects the applicant to a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS FIXTURES
-
_
not marc than Ove hundred dollars (Sem).
❑ Lthewrk,anhepmperty,orm
NEW RESIDENTIAL ELECTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will dothewort, and the of imenyeeswlthwagesasthei(Sec.7AJ1,Bua0pu,
Business
and Professions Code: The Cont License Law does not apply to an owner of
he Coreisnotintendedor-offeredforotapplyt an
emorx
his
propemploycesrty ,prolds nrimpmveschimpr andwho doenmatandeds such mortared
own employees provided that such improvements erenotimended proffered forsale.IL
OCC GROUP
RES. UNITS
TOTAL:
however. the building or improvement is sold within one yearofcompletion, thet wner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale).
❑ L as Owner afthe property, am exclusivelycontrading with licensed remnants to
FLOOD ZONE
APN
onstme, the project (Sec. 9044, Business and Prokssions Code:) The Contractor's
License Law doesnot.p,ty loan ownerofproperly who builds or improves thereon, and
PERMIT ISSUANCE
who contracts far saeh projects with a contractors) licensed purses ant to the Contractors
License Law.
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSID S
SANITARY Y N
RECEIPT#
Owner Data
DRAINS FLOOR, ROOT, ARRA,GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherehy affirm that l have a cenifiwte circulator to self -insure, or a cenifiwte of
Workera Compensation Insurance or a cenifedcopy thereof (Sec. 380, Lab C.) which
covers all employee's under his permit
Policy #
FIXTURES - PER TRAP
PARK
PARK FER Y N
RECEIPT#
GAS - EA. SYSTEM -1 INC. 40UTLE1'S
BUILDING DIVISION FEES
Company
GAS -EA. SYSTEM -OVER )
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREASEANDUSTRL ASTE INTERCEPTOR
GRADING HE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP'
S SITE
COMPENSATION INSURANCE
SEWS -SANITARY-STORM FA. 200FT.
HR FEE
(This section need not In completed ifthe permit is fomne hundred dollars (SIM)
or less)
WA HEATER W/VENT/ELECTR
\
I certify that in the performance offle work forwhich this permit is issued, I shall
not employ any person in any manner so a t e n t [ to the Workers'
Compensation Lave of Cslifo t D
P ID
Date Receipt#
WA T SYSTF.MrOUiATING
Applicant, Y
.NOTICE FDA (CANT: If, after makingr}tis Celfifleate of Exemption, you should
NEW RES DENTIAL PLMB. . FT.
TOTAL
become subject to the Worker's Compensation provisions of the Labor Code, you most
tonhwith comply with such provisions or this permit shall he deemed revoked.
UiLDING FEE `
SEISMIC FEE f'U
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency for the performance of
the work for which this permit is issued(See. 3099, Civ. C.)
TOTAL.
ELECTRIC FEE
Lender's Name
j
QTY. MECHANiCACPERMIT FEE
PLUMBING FEE
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE \ /
MECHANICAL FEE
building construction, and hereby authorize representatives of this city to enter armadas
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECIL \
CONSTRUCTION TAX
agree to save, indemnify and keep harmless the City of Cupertino againstliabildies,judgments,costs
andex,scromwhich may in any way accrue hind is 'dCity
wnsequence♦♦♦ffffhhh grams Ithis pe It
�27,
AIR HANDLING UNIT(TO 10,000 CFM)in
AIR HANDLING UNIT (OVER I,mOCFM)�—
EXHAUST HOOD(W/DUCT)
N
PAID
Signat�ureof Apppplicant/Commetor 2 �y�%%mate
'
HEATING UNIT (TO I100,0000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER IOO,IXIp BTU)
TOTAL: 17.
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
VBN9'ILATION FAN (SINGLE RPSID)
11 Yes 13 No(We)
Code, Section 25532(a)Y
Dy'ATH
defining by the Bay Area it Q ality Manich agement
Will air t
haznrdous air contaminants an relined by the Bay Area Air Quality Management
Disvict? '
BOILER - COMP (3HP OR 1m,Om BTU)
rISSUANCE
BOILER- COME (OVER 1011,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
❑Yes El No
. I have read the hazardous materials requirements under Chapter 6.95 of the
Ju% y
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a renant, that it is my responsibility 0 notify the
tter.lon, of the mqutreas ms which must be met dm,. issuance of a Ceniticme of
!v I I Y VF V V r C j j 1114 V
b
Occupancy.
f
ISSUED BY
Owner in authadi,ed agent Date
TOTAL:
OFFICE V