280811 r
APPLICANT TO FILL IN INFORMATInN WITWIN Ren 111,11=0 -lice g.. e
--------------------- --------- .r.r...r —'sa,I
CITY OF CUPERTINO x ILDING-ELECT 11 AI.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
PERMIT NO,
28081
AUILUING PROJF.(TI' lUF1NrIFI(]AO
1TN
ILDING ADDRESS:
\ —
fl LOT#
SANITARY NO.
APPLICATIONSUBMMAL_DATE•
71
OWNS M ,a P_�
CONTRACTOR'g NAMI?: hIC NO:
N/C CONTROLp
❑ '
lrilse(�aV
RCHI'ICCT/FNGINIi 7HONE:
RES
CONTACT:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Z I hereby affirm that l am licensed underpmvisionsofChapter9(commencing with
O full iore(and efcivisionJnf the Business and Prnfeasinns Code, and mylicense ix in
fall force and effect.
APPLIANCES -RESIDENTIAL
PANELS
CRIPI'ION
UG
W License Clsss Lic.p
in Dau Camncmr
UPT020OAMPS
201 - 10(10 AMPS
K ARCHITECTS DECLARATION
0 1understand my plans shallbeused public record,
atSIGNS
SQ. FT. FLOOR AREA
S/SQ. FT.
OVER 1000 AMPS a
ELECTRICAL
Lmcnud loo—amon
J DECLARATION
I hereby affirm OWNER -BUILDER that I sm exempt from the Computers License Law for the
A following ream.(Section 9031.5, Business and Prnfessionx Code: Any city Oremmy
which requires a permit to constrict, alter, improve, demolish, or repair any structure
PH., to its issimme,lsn requires theapplicant for such Permiuo filen signed stmemem
D that he is licensed pursuant to the Provisions of the Contmcmr's License Lew (Chapter
i 9(commencing with Section?") of Division J of the Businessanl Professions Code)
N or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars (SSW).
❑ I,asownerofthep Np.ormyemployaswithwageOtheirsolecompmadon,
_ willdothework,mdthesTact.reisnmimmndedoroffen forsale(Se:.7N4.Busiwsa
SPECIAL CIRCLITDMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIST 'ORES
NEWRESIDENTIALELECfR_SQ. IH'.
STORIES
TYPECONSTRUCION
and Professions Code: The Comrences License Law does not apply tom owner of
property who builds or improves thereon, mdwhodoes such work himselfm through his
own employees, provided that such improvements arennt intended moffemd forsale. If
however, the buildingor improvement is sold within one youmfcomplction, the owner:
builder will have the burden of pmving that he did Out build or improve for purpose of
OCC GROUP
RES. UNITS
TOTAL:
sale.).
QTY. PLUMBING PER FEB?
❑ 1,usownerofthepmpeny,a exclusivelyconnaaingwithlicensedcontrdctomro
construct the project (Sec. 7044, Business and Professions CW,:) 'rhe Canrncon,
FLOOD ZONE
APN
License Law does not BPplyto anownerofpropeny whobuildsorimproves thereon,and
PERMIT ISSUANCE
who embane for such Projens with a cidamemrts) licensed pursuantto the Contractee s
License Law.
❑ 1 em exempt under Sea , B & P C for this reason
ALTER -DRAIN&VENT-WATE )
BACK PLOW PROTECT. DEVICE
FEE SUMMARY
DR Pli
OwnerSANITARY
Date
DRAINS- FLOOR, ROOF, AREA, COND.
Y N
RECEIPT
WORKMAN COMPENSATION DECLARATION
❑ theComperntiontlhrance icenrie copythi
is
SCHOOLTAX Y N
FIXTURES - PER TRAP
sel(Sec, 38or Lab C.)c which
or
Wakers'Cmployeesnler this Insurance or ified copy thereof(Sea JSW,LabCJwhich
ere ell employees under this permit.
Policy #
RECEIPT#
PARKME Y_N
RECEIPI' #
GAS - HA. SYSTEM.[ INC. 4 OUTLETS
BUILDING DIVISION
Company
GAS - EA. SYSTEM-OVER4(FA7
FEES
PLANCHECK FEE
❑ Cenibedcopy is hertby famished.
❑ Certified copy is bled with the city inspection division.
GREASExNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CER' T'IFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GRHASETRAP
SOILS FEE
Mis section need not becompleted ifthepemtit is foram hundred dollars(SIW)
or less.)
SEWER - SANITARY - STORM PA. 2WFT.
ENERGY FEE
I cenify that in the performance ofthe work for which this Permit is issued, l shall
.at employ any person in any manner so as to become subject to the Workers'.
CAom[�'atinn Lawsof Califnmia. Date
PP
WATER HEATER W/VENT/ELECTR
PAID
Date ceipt#
Re
WATER SYSTEM?BEATING
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation Provisions of the Lahr Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
NEW RESIDENTIAL PLSUL SQ. PT.
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affimr that there is a coastruction lending agency fa the prmfmmmrce of
the work for which this permit is issued (See. 300, Civ. C.)
Lender's Name
SEISMIC FEE
TOTAL:
ELECTRIC
Lender's Address
QTY. MECHANICAL PE'RMI'T FEE
PLUMBINGP
1 certify that I have read this application and slam than the above inf dan don is
PERMIT ISSUANCE
MECHANICAL ME
cometl agree to comply with all city and county Ordinances and state laws relating to
built ingeonstruction, and hereby authorize representatives ofMschy to emcrupon the
above-mentioned property for inspection purpous.
(We) agree to save, indemnify and kap harmless the City of Cupertino against
Iiabilities,judgmems, costs andexpenue which may in any wayicerue against said City
in con.mai eof the granting is Ferrol.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (To to," CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,"CFM)
Si nawre Applican naacror I Dam
EXHAUST HOOD(W/DUCn
PAID
HEATING UNIT (TO 103,000 BTU)
HEATING UNIT (OVER M." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare en handle hmmdous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
hos, Receiln#
/ '/� a'OTAL:
Code, Section 25532nd?
❑ Yes ❑ No
VENTILATION PAN (SINGLE RESID)
...-
Will thea licmtorfumrebuildin
pp gby the ay equipment Quality Management hazardous an contaminants m defined by the Buy Arca Air Quality Management
District?
- ❑ Yes ❑ No
BOILER- COMPUIHPOR IW,OW RTU)
I ATE
y �p
y V
BOILER- COMP IW,000 BTU)
NEW RESIDENTIAL MECH.—SQ. IT.
I have read the hanrdous mnterials requirement. under Chapter 6.95 of the
Califnmia Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building rias at currently have n tenant, that it is my responsibility m notify the
pant om
f the requirements which ust hm an
e met prior issuao ma Certificate Of
ownmpaney.
BY:
Owner or nuthonud agent Dune
TOTAL: ISSUED
OFFICE