28220 (2) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELM E HICAL FERMI"r NO. 282 w w �O
APPLICATION/PERMI'P PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PRO)E(:'r IDENTIFICATION L{�.(7•LJ
BUILDING/ADDRESS: SANITARY NO. APPPILICCA'DOO�N SUBMITTAL DATE;
UNIT# LOT It
OWli� O": CONTRACTOR'S NAME: LIC NO:
N/C C(JMROI.
RC IIEQ/ENGIER:
LIC NO: ADDRLin ❑
10 CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MliCll
PERMIT ISSUANCE ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL.
JOB DESCRIPTION
Q C 7 I herebyaf6rn that l am licensed under provisions ofaspmr 9(commencing with
4100 Section 7001)of Division 3olme Murines,and Pmfbasinm Code,and my l icense is in PANELSde fall forcestural effect.
(''�
UU L¢cnse Claus Lic.# UPT03W AMPS Stu ` v
to Dam Camraclnr 201-IOW AMPS SQ.Ff.FLOOR AREA S/SQ.FT.
F'z ARCHITECT'S DECLARATION OVER IM AMPS
zo,o— I undersmnd my pImo,h.II be used.,wh1svoer d,.
O Z F Pit SIGNS ELECTRICAL
QN�j Licensed Professional
4�ne< OWNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC.
xdOiU
I hereby if,.that 1 em th
exempt from e Conrnore alicense Law for the
413 LL y following reason.(Section 7031.5.Burros,,and Professions Code:Any city m county TEMP.METER OR POLE INST.
tut ON; which requires a permit to construct.alter,improve,demolish,or repair any.sumemre
f >.;_; priorm its issuance.also requires the applicam forsuch .is filcasigndsmtemem POWER DEVICES
rs
,W<C) that he is licensed puuant to the Provisions ofthe Coamnm's License Law(Chapmr SWIMMING POOL ELECTRIC
a-Lo�' 9(commenciog with Section 7W)rr is 3 ofthe Business and Professions Code) VALUATION
Way or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTlIRFS
ty¢ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than Five hundred dollars(5500).
SYQ NIiW RLSIDENtIAL EL[CTR _SQ.FT. STORIES TYPE CONSTKUCTION
uuK11Fo ❑ offiew rorthe prnperty.e isi employees withered f a.]. selcc0,14,B craw,
will Professions
and the xhe.hare Contractor's Liddrr offeredsnot apply 2004.Business
and Professiom Cede:The Contractor's Lias¢Law does not apply to an owner of
property who build,or improves thereon,and who does such work himselfor through his OCC.GROUP RIS.UNITS
wn employees.providedIbut such Improvements um not intended or efl"emd for rule.If.
however.the building orimpoovemem is sold within one year ofcompletion,theowner- L.
builder will have the burden of proving that he did not build or improve for purpose of
wl QTY. PLUMBING PERMIT FEIi
ref the pmpeoy.amexclusivelyconractingwith licensed contractorsto FLOOD ZONE APN
maxum thcrpmjat(Sec.'IW4,Business and Professions Codr:)The Cmdacu 's
License law does not apply low owncrofpropeny who builds orimpmves thcrwn,and PERMIT'ISSUANCE
who crnitmctsfort mcM1 pmts.wnM1ocomracmrts)Iicensedpursuanuo die Conuacmr's ALTER-DRAIN&VLM O-WATER FA FEE SUMMARY
License Law.
m
❑ 1 aexempt under Sec. .B&1'C for this reason OUTSIDE IEES
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Da¢ DRAINS-FLOOR.ROOF,AREA.COND. RECEIFTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihembyaffvmtbatlhaveaccoifeaeofconan,toxlf-in,ure,oracetiFcalcof FIXTURES-PER TRAP RECEII'Tp
Workenc Compensation Insurance or a evi ifed copy lM1cmal'bec.3800,Luh C.)which PARK FEB Y N
rs all employee's under this permit. GAS-FA.SYSTEM-I INCA IETS RECEIPT'#
Pal'�c"# BUILDING DIVISION pEF_S
Company GAS-EA.SYSI ' ) PLANCHECK FEE
❑ Cronies]copy is hereby furnished.
❑ CenitioJ copy in❑Tal with the city inspection division GREASE/INDUSIRLWA INTERCI GRAVING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE?
(This sectionncediul be completed ifthe permit is Return hundred dollars($100) S E WER)&Y- r. ENERGY FM
or less.)
I certify thin in the performance ofthewmk for which this permitstriad,I shalt WAT :A'I?R /VENT ,LF
nm employ any person In any mann.,so as or box.subject m the WorkersPAID
Compensation Luwsof Calltomia. Date WATER SYSTE EATING Dale Receipt ss
Oz Applicant
z Z NOTICE TO APPLICANT:If,ober making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
t-+ y bcaomeuuhjen to the Workers Compcnsullnn provisions of the huMn Code,you must #� / BUILDING FIiE
— forthwith comply with such provisinm or this permit shall he deemed revoked. O
1 Q CONSTRUCTION LENDING AGENCY SEISMIC LEI?
z I hereby affirm that there is o construction lending agency for the perfmmwce of ELECTRIC EEE
U Q the work for which this prom,is issued(See 3097,Civ.C.)
Lender's Name
D" F LandersPLUMBING FEE
Address QTY. MECHANICAL PERMIT FEE �-
U 1 omit,that I have read this application and slate that the above information is MSCI IANICAL FFai
LIJ correct.lagramcomplywithallcityard....tyordmancraird,mtenwsreladr,an PERMIT ISSUANCE
h-' building construction,and hereby aurbi representatives of citym enter upon the CONSTRUCTIONTAX
(� 'z uhove-mentioned property l'nr inspcnion purposes. ALTER OR ADD TO MECH,
(We)agree m rave,indemnify end kap harmless Cit of Cupertin
liahilities.judgmrms,wsu undeapcnxs which mu in way aroengainstand e.g.Ciry AIR HANDLING UNIT(TO I0,000CFM)
�Inc m,eyucn of the gmlttiv8 nllhis n
AIR HANDLING UNIT'(OVER ID.fXgl CFM)
of A,icwUCnntmdor Date IiXHAUST IIOOD(WlDUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE 1/ l ' TING UNIT(TO 100,INX1 BTU) Dae Racip#
n Will the applicant or future building occupant store or handle hassrllKFale'
is defined by the Cupeoian Municipal Code,Chapter 9.12,and the Health anSa y 1 (OVCIt I00.tl00 BTU)
Cute,Section 25532(a)? VEM'ILATION FAN(SINGLE RESID)
❑Yea ❑No
BOILER-COMP(3lIPOR 100.000 BTU) ISSUANCE:VATE
Will thcapPlicantnrtuwre building nccupam meequipmemnrdevices wM1ichemit /T p
buardous atr contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) gq e
Ulstrid?
AS ❑Yu ❑No NEW RESIDENTIAL MECIf.—SQ,Fr. /�
1 have rend the haganlmlx materials reyuircmems under Chapter 6.95 of the W �B n
C.lifo.I.Health&Safety Code,yahoos 25505.25533 and 25534.I understand that �s �J
if the building dos not currently have a Room.that it is my responsibility to notifythe y/ Y(JF �.
occupant of the requirements which must be met prior nt issuance of u Cerifienle of �.
fXcupaney.
Owner or in,dameed agent Date TOTAL: ISSUED B
OFFICE