28238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPL'RT,INO BUILD:,N m-ELEC'I'RICA]. PERMIT IS028238
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APPLICATION/PERMIT PLUMB NC-MECHANICAL
L l}J( L <J VX
BUILDING DIVISION BUILDING PROJECT'IDEN'I'IF'ICAI'[ON
IILDINGA DDDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/O/(^ d
UNIT a LOT#
OW �R/S/NAMMkE:: jh� cSPI10NE C RACTORS ME/ LIC NO:
1-74"141 y //(N Z Z D� G N/C CONTROL#
\RCHITF. f/FiNGINF,ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT I.UMB MECH
PERMI IISSUANCE ❑ ❑
LICF,NSCD CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyZ I hereby ofGrm that l am licensed underprovisiomofChapter9(commencing with
p:OO Section7")it ofvelvieionJof the Rosiness and Professions Code,and my license is in PANELS
yW_
P. full force and effect.
FV UUP TO 2a)AMPS
Z W License Class Lic,p
mDC DateCnmmclor 2U1-IOIXIAMPS
FyZ ARCHITECT'S DECLARATIONSQ.FI'.FLUOR AREA VSQ.FT.
ZOoz—o rn^ 1 adersmndm I shut lx used as public records. OVER 1000 AMPS
_ rpmt.a
F^F; SIGNS ELECTRICAL
Licensed Pmfcasinwl
�C)Wu OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISE.
dOL V I hereby affirm that 1 am exempt from the Contractors License Law for the
u Say following reason,(Section 7031.5.Ba.siness it Professions Code:Any city m oinaty TEMP.METER OR POLE INST.
F a O< which requires a permit to consumer,alter,improve,demolish,or repair any structure
fy>� to its issuance.aloun ac the livor ku,ach nit to file nsimeinmcmem POWER DEVICES
prior 4ui PP pen b
S,
C O O that he is licensed pursuant m the provisions of the Cnmanor's License law(Chapter
aXOE 9(comntencing with Section 901%Ilof Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
r-j❑,o, or that he is exempt and the basis for alleged exemption.Any violation of OUTLETS-SWITCHIS-FI%TURF•S
P.y)- Section 9031.5 by any applicant for a Pemd...bjects the applicant to a civil penalty of
ac2 rn than Bva M1undodny,onmye pl NEWRESIDENDALELECTR _SQ.PE STORIES TYPECONSTRUCrION'
KFz sowncroDhc propcny,ormyemployeeswith wagesas lh<iranlecompensauion,
p�,s_ will daaewons std the structureistot is License Law
sal apply t0 an owner
and Professions Code:The Contractor's License law es such
not apply lf an owner is
onme
properlyho provided
imphat such amprov opens ,,ami emba himsdfor through hi.v
employers,provided lhau such improvementsar<nosintendcd oroffcrW Tarsale.If. OCC.GROUP RES.UNITS
however,the building or improvement i.s mId within one yearofcampledon,theowner. TOTAL:
builder will have the burden of proving that he did not build or improve for purlmse of
sale.).
❑ I,usowner ofthe property.amex<lusively containcontractors with licensedcontractorsQTY. PLUMBING PERMIT FEE
acnrts uo FLOOD ZONE qYN
commicu the project(Sec.9014,Business and Professions Code:)The Contractors
Liceme Lawdocsnm upplylamowncrofMproy who builds or improves thereon,andPERMIT ISSUANCE
who contractsforsueh pampers with acontmero(s)licensed purua
snt m the Contactors WATER FA
License Law. ( ) FEE SUMMARY
❑ I am exempt ander Sec. ,B&P C for this reaso
B OUT SIDE PEES
N,FLOW PROTECT.DEVICE Y . N
Owner Date DRAT -FLOOR,ROOF.AREA.COND. RECEIPT#
WORKMAN COMPENSATIONDECLARATIOry SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate at consent o self-insure,ora nifcareof RECEIPTN
Wmkeri Compensmionlnsumnaoracenifiedcopy Ne l(Sec.38W bCJFI%TUBI -PER TRAP wNch PARK FEE Y N
m u11 employee's anderthis Permit. GAS-EA.. STEM-I INC.40V�LBI'S RECEIPT'#
policy p BUILDING DIVISION FEES
Company GAS-EA.SY.TEM-OVFE 4(EA) PLANCHECK FEE
❑ Certified copy,is hereby famished.
❑ Certified copy is filed with the city inspeniondivis GREASEWSDU. L WASTE INTERCEPTOR GRADING FEC
CERTIFICATF.OPEXEMPTIONFR MWORKERS' REASETRAP SOILS FRE
COMPENSATION INSU NCE
('ifiissecuionnc notbecomploWifthepermi isforonchundreddollarUS ) SEWER STORM CA.2WFT. ENERGY FEE
or less.)
I certify that in the performance of the work for ich this pe ,L all W TE I. W/V '1'/ELECTR
not employ any Person in any m as to be rate sub' u Works: PAID
,� Compcnmtinn Lawxaf Califomia.manner
so WA RSYSTHMI . T 'G Date Receipt#
Applicant
I- NOTICE TO APPLICANT:If.after making this Cedificme 'Exempti yau.shoaW NEW RESIDE IAL PLMB. SQ.FT. TOTAL:
ybecome sabjeerto the Worker.,Compcnsauon provisions-' 'Mr Code,you mon
> fonhw'nh comply wi th such provisions or this pemtit shall be dee edrevoked. BUILDING FF:E
RWs Q CONSTRUCTION LENDING AGENCY / SEISMIC FEE
I hereby affirm that there is a construction lending agency ftrthe rouranceof
U O ]iLECI'RIC TEF,
the work for which this pemnt is issues(Sep.3099,Civ,C.)
Lender's Nance
U"' F Lenders Address Q' MECHANICAL PERMIT FEE PLUMBING PF,E
U I certify that 1 have read this application and stare that the above iial1kration is MECHANICAL FEF.
correct Iegave to comply with all city and county ordinances and state law sr acing to PERMIT'ISSUANCIi
I" building construction,and hereby authorize represemativesofrhis city toenmsu CONSTRUCTION TAX
V Z ahovoaemioned progeny for inspection purposes. ALTERORADDTOMF.CIL
(We)agree m save,indemnify and keep harmless the City of Calandra,against
habil'nics,judgments,costs and expareswhich may In any way accrue against said City AIR HANDLING UNIT(TO 10.WO CFM)
in con ucncc of the grarifng of 's pcm,il4 iv/�I9 5
f,YIJ AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicam/Comrenor Date EXHAUST HOOD ONMUCO PAID
HAZARDOUS MATERIALS DISCLOSURE ::EATING UNTr('I'U 10011x0 FIT'U) Date Rccctry#
will the ap,lurru or future biddingrwcnpant norc or handl.harurdoes material HEATING UNIT(OVER❑10,000 BTU)
TAI'
as defned by the Cupertino Municipal Codc.Chapter 9.12,and:M1e Health and Safety
Cale.Section 25532(0)'!
El Yen ❑No VHNTILATION PAN(SINGLE RIiSID)
ISSUANCE DATE
Will the applicintorfutumbuildingoccupanl aseequipment ordeviceswhichemlt BOILER-COMPCIFIPOR 100.1100 EFFID q /�
hazardous air comaminants as defined by the Bay Arca Air Quality Maniumem 110 BOILER-COMP(OVER 100.0BTU) P� A D
District?
40 ❑Yea 0 N NEWRFSIDENTIALMECIl. SQ.FT. /n
1 have read the hazardous materials requirements under Chapter 6.95 of the JUN 28 1995
Culdro is health&Safety Code,Sections 25505,25533 and 25534. l understand Nut Cqy VJJ
if the building does not currently have a tenant,that it is my resprmlbility to notify the / Ur
oceupant of the requirements which mon be mcu,nor m issaunce.f a Certificate of
Occupancy.
Owner or nuthonont agent Date TOTAL: ISSUED BY:
OFFICE