28000 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO
BUILDING-h TRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANI
UUILUINC PROJRCI'1UBNTIFF-ICICATIUN 28000 8 L O0 0 0
BUILDING ADDRESS:INO:
JJ .�^ D-,1I _ SANITARY NO. APPIICAATIO/NSSUBMMIT'V/AL^DATF,
2:zg71 LOA („GWn UNIT# LOTH
( NERS NAME: PHONE: CO TO N LIC NlJ J
AS
r Har QI NC CONTHOLN
RCHI'IECI'/' GINIiLR: LIC NO: ADDRESS: ❑
14
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
Pill Ml:cx
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
pCZ Iherebyaffrtn that lam licrnud under provisinnsofChapmr9(commencing with
4100 Section 7")of Division 3 ofthe Business and Profession Code,and my license is in PANELS
CU� full force and effect. 1 i
p6„Zw License Class Lic.# UPTO200AMPS
why Dam Commend 201-IM AMPS
r-VZr ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
A
pQ 1 underhand an,plans shall he used as public records.
ry W SIGNS ELECTRICAL
a4 J Licrned Professional
RJ UUUUG OWNER-BUILDER Farm
the CoATION SPECIAL CIRCUIT/MISC.
O 1 ng bbyanu b ntran(Se that 1 an exempt from the Contributors License Lew co the
,N:,,,.,Owhich ng reason.(Section 7031.5.Buainess and st,.&ion Code:Any city m county TEMP.MH'IER OR POLE INST.
J wM1ich rtyuiru a permit ro c.mwa,atter,improve.demolish,m¢pair any structure
.tflY2 prior to its issuance,also reunites the applicant for such Permit o fit e..ignedemmmam POWER DEVICES
W off' 0that he is licensed mosmnt to the provisions of the Contractor's License Law(Chapter
4 k'0. 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC a� _VALUATION
W K or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
-SWITCHES-FIXTURES
IN4
Section 7031.5 by any cold cantfor a permitaubjects the applicanno.civil penalty of OUTLETS
not more than five hundred dollars($500).
❑ I,uownemfthepropeny,ormyemploymswitliwapsms elrselecompensation, NEW RESIDENTIAL E CTR —SQ.FT. STORIES TYPE CONSTRUCTION
a3— will do the work,and the stmemre Brad intended suffered for sale(Sec. Business
and Professions Cale:The Contractors Lt...Low does not apply on an owner of
property who builds or improves domem.and who does such work himself.,through his 00C.GROUP NES.UNITS
n employees,providedrhatsuch improvements amn.t intendedoroffered forsale.If,
however,the building or improvement is sold withinoneyearofcompletion,thehwner- T �r
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mownerofrhe property,am exclusively contracting with licensed contractors to QTY. PLUMBING IT FEE FLOOD ZONE APN _
construct the project(Sec.7044,Business and Professions Code:)The Contractor's r
pHRMIT ISSUAN
Licensetawdoes nm applymanownerofproprny lihose Idsimprovesthereon,and
who contacts for such projects with a contractors)licensed purarsuanUo Ne Contractors
License Law. ALTER-ORAINffi VE ( FEE SUMMARY
Cl1 am exempt under Sec. ,B ffi P C for this main 011105
BACK FLOW P0. EV
Cf.DIC
SANITARY Y N
at
Owner Dae DRAINS-FLOOR,ROOF,AREA,CON RECBIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
_ ❑ Iherebyaffrmthatlhaveacenificem of consrnno self-insure,oracertifmte of FIXTURBS-PER TRAP RECEIPT#
Workers'Compensation Insurance ora certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y_N
covers all employce'e under this permit. RECEIPT IF
Policy# GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Candied copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREA$F.TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundred dollars($10o) SEWER-SANITARY-STORM PA.201 ENERGY PEE
.,less]
I cenity thin in the perfsrnanceof the work for which Nis permit is issued.)shall WATER HEATER WNENT/ELECfR
not employ any person in any counter so M to become subject to the Workers PAID
Compenamionlawsuf Califonia. Date WATER SYSTEWTIFEATING Data Feeci,d0
Q ,Z Applicant
0 NOTICE TO APPLICANT:I L after making this Cenificd,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
En become subject to the Workers Compensation provisions of the Labor Code,you must
�i 7 forthwith comply with such provisions or this pandit shall be deemed revoked. BUILDING FE
LkI Q CONSTRUCTION LENDING AGENCY SEISMIC PER
z 1herebyaffirmrhntthem is (See.
agency for the performance of
O Ne work for which this rot
Permit is iuued Jan].Civ.C.) prj ELECTRIC FIiE
Lenders Name
OF" Fail Address QTY. MECHANICAL PERMIT FEE PLUMBING MEL
W1 certify that I have read this application and state that the above information is MECHANICAL FEE
0. correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authorize representatives of Niscity to enter upon the CONSTRUCTION TAX
V above-mentioned property for inspection purposes. ALTIiRORADDTOMECH.
(We)egr to save,indemnify and keep harmless the City of Cupertino against
Imbilities,ju ents,costaandexpc hichmaymanywaysecrmagainst said Ciry CFM)
AIRHANDLINGUNIT(TO10,0111i
in m�sequ of the granting of it.
_g AIR HANDLING UNIT(OVER 10,000 CFM)
St...it of Applica t/Ct Dam EXHAUST HOLD(W/DUCH PAID
II LAR US MATERIALS DISCLOSURE HEATING UNIT(TO I0g00)BTU) Date Receipt#
Will the upplic tar fmure building oecu. store.,handle hazardous material HEATING UNIT(OVER 100,(1000TU) TOT
as defined by the Cupola..Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532p)P
❑Yea 11 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will thea licanr or fltuxbuildin occu tux cordevices whichemit BOILER-COMP(3HPOR 100.011013TU)
PP B pan Area it
hmardous air contaminants m defined by the Bay Area Air Quality Monagemrnt BOILER-COMP(OVER 100,000 BTU)
Gordo 1 p '
❑Yes ❑No NEW RESIDENTIAL MECH. %
SQ.FT.
I have read the hemdous materials reyuiremrnas under Chapter 6.95 of the
California Health ffi Safety Cade,Sections 25505.25533 and 25534. I understand that to
if the building does not currently have a want.that it is my responsibility to notify Ne T9.
occupant of the requirements which must be me prior to issuance of a Certificate of C/1p r t.- a�
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: Il O
OFFICE