28308 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28308
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'IN
OW ESNAME`� PEON C:�� CD Cf^S NA r:� ^ LIC NO: NC L,CONTROL#
Nil LOT#_
CHITECI'/ENGINEER: LIC N88: AD >Q DD 1^ ` ❑
NTACT: PHONE: ` t BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
P17RMITISSUANCE ❑ ❑ 4K E]
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIP'1'ION
OKZ, Thereby offrmthatl amftheB ,inderprov rofe,,of Chaptcr9(comy heroic wish
W�00W— far
omeanDmf Division 3nf the Business and Prnfcssions Cnde.and my l'ncnsc is In PANELS
<W� full force and effect. , Y
l yZW License Clans Liu 11 UP'1'02MAMPS
tray Dae Contmeter 201.I"AMPS
Sm
2 ARCHITECT'S DECLARA'T'ION OVER 1000 AMT'S SQ.FT.FLOOR AREA S/SQ.FT.
oz-0 r I understood my plana shall be uird las public records.
r yF� ceSIGNS ELECTRICAL
�d ,
Licenced Professional
Lx�a a OWNER-BUILDER DECLARATION SPECIAL CIRCUTI'/MISC.
W 3 1 hereby affirm that I am exempt from the Convector's License Law for the
following mason.(Section 90313,Business and Professions Cale:Any city or county TEMP.METER OR POLE INST.
k IS0a which requires a permit to emournct,etre,,improve,demolish,m repair any stncture
KWQ� prior to its is,aaacc,dso rcyuiresthanpplierm forsun
ch Fromo file aslgred statement
POWER DEVICES
yIKOp that he is licensed pursuant to the provisions of the Contractor's License Lia,(Chapter
daxo 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL EL17CIRIC VALUATION
W_y of that he is exempt therefrom and the bmis for the alleged exemption.Any violation of OU'REfs-SWITCHES-FIXTURtS
N4 Scotian]031.5 by any applicant for a petmitsubjects theapplicamtn.civil penalty of
0 not more than five hundred dollar,($500).
o ❑ I,aeownerofNepropemy,ormyemployuswiNwagesastheirsolecompenation, NHWRESIDENTIALELECfR _SQ.FT. STORIES I YPE CONSTRUCTION
0. :.o will dothework.and the swcwre is not intended oref(ered forsule(Sec.1044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who buildsorimpmvesthemon,andwhodoessuclt work hlmselfor thrnghhis OCC.GROUP RF:S.UNITS
ownemployees,provided that such improvementsarcnot inuender croffered forsale.If,
however,the building or improvement is sold within one yearofcompletion,imewner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lnownerofthepropeny,amexclusivelycontrvctingwithlicensedcnntmctorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE. AI'N
construct the project(Sec.70,PL Business and Professions Cale:)The Contractor's
License Lawdess not apply to anownerofproperty who buildsor imp r.vnthereon,and PI7RMIT ISSUANCE
whe contracts for such projects with a amtructor(s)licensed pursuant to the Contractors PESUMMARY
Locate Law. A1RER-DRAIN&VENTI,.WATER(HA) v
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE q 1 E h
SANITARY Y_N
Owner D:ne r RECEIPT'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN CD I1I7NSA1'10 lE ARA'T'If SCHOOLTAX Y N
I hembyaffirm thin l have.a reammfe m - uself-inar or aenifcncof RECEIPI'q
orker#Cron tion Insurance en a �/,a FIXTURES PER TRAP
rsall employee's under this perm °ythereq}ji ce,a8 bC.l which PARK FEE RECEIPTtl N
3 L/ GAS-EA.SYSTEM-I INC.40U LEI'S
Policy M BUILDING DIVISION PEES
Cm"P.Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ CenifieJ copy is hereby famished.
❑ Certified copy is fled with the city inseti ninon. GRP.ASE4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G ET P SOILS FEE
COMPENSATION INSURANCE
(Thissection need not be completed ifthe permit is forma¢hundred dollars(SIM) SE R-S 1'fARY-STORM GA.201 ENERGY ME
or locos.)
I certify that in the performance of the work for which this permit is issued.I shall BR H PAIR WNENT/ELECI'It
net employ any person in any manner so as m become subject to the Willa s' PAID
Compensation Lawsof Califomia. Date WATER SYSTEM[IREATING Date Receipt#
0 z Applicant
0 NOTICE TO APPLICANT:If.afirruoking this Certificate of Exemption,you should NEW RESID17N TIAL PLM 13, SQ.FT, TOTAL:
V] become subjecno the Workers Compensation provisions of the Labor Code,you must
Fa' forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FBI!
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
VZ l hereby affirm that them is a constmction lending agency for the pefformwce of TOTAL: ELECTRIC PGE
O the work for which this permit is issued(See 3097,Civ.CJ
ty I<nder's Nome
L-� T<ndera Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U I comity that I have read this application and store that rite above infmmaumn is MECHANICAL FEE
correct.l agree to comply with all and county ordinances and stem laws mlating to PERMIT ISSUANCE
buildingennstruction,na yamhori a representaiveso(this rayon enreruponthe
U 7 .hove-mention¢ crty for inspection purposes. ALTER OR ADD TO MI?CII. CONSTRUCTION TAX
ace los mmfy and keep harmless the Cily of Cuperl ino against
I' nes.judgment.c.", xpr su which mayin any way accrue against said Ciry AIR HANDLING UNIT(TO 10,003 CFM)
In off a fi it.
., AIR HANDLING UNIT(OVER 10.0MCIN,
Signa f plicanVCmooa,mr Date IXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNTT(TO 103,010 BTU) Date Receipt If
Will the applicam mr furore building occupant store 0r handle havudrim mmcdol
as defined by the Cupertino Municipal Cale,Chapter 9.12,land the Health and Safety I MATING UNIT BUYER 100,000 BTU) '1'O"
Cade,Section 25532(a)'I VENTILATION FAN(SINGLE RFSIU)
❑Yes ❑No
isp
BOILER-COMP CHP OR 100,000 BTU) ISSUANCE DA TE
Will the contaminants
building by the Bay A Air orroln, swhigersom AUG 07
dill
air mntaminnnta as defined by the Boy Aren Air Quality Management BOILER-COMP(OVER 109,000 BTU) A
isvict7 /s 1
❑Yes ❑No p NEW RESIDFN'1'IAL MI?CII. SQ.Flt till l✓r tit(995
I have most the Limitations materials requirements under Chapter 6.95 of the Lour
Califomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
Occupant or the requirements which must be met prior to issuance of a Certificate of
cupancy.
Owner or authmi,ted.,cut Dote TOTAL: ISSUED BY:
OFFICE