28198 APPLICANT TO FILL IN-INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITIrOF'CUPERTINO Hui CITING-ELECTRICAL PERMI'TNO. ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 28198 O 1 n O
BUILDING PROJECT IDENTIFICATION - G o 1 J o
BUILDING ADI ESS B SPN VTRO LOTp �� SANITARY NO. APPLICATION SUBMITTAL DATE
05
OWN RJ5110 p /SPH ONTRAC9'OR'S NAME: LTC NIC CONTROLN
Ilk
RCHITECT/T:NGINF,F,R: LIC NO: D R SS: [Zr,I,✓ ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT BUILDING PERMIT INFO
BI.120 ].GCT PLUMB MECH
PERMIT ISSUANCE.
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ortiz I hereby affirm that l am licensed undefprovlsionsafChapter9(commencing with - JOB DESCRIPTION
[Ft00 Sectloa700@of Division. tithe BusinestrimP daseio sC ,aadmylicanseisin PANELS rel
few full force and effect
z9L
¢ µ. blls, » UP AMPS S LU t—,
Fay Contractor 201-1000 AMPS
z Of"ir'4 ARCHITECTSDECLA TIO OVERT 000 AMPS
Oz„ SQ.FT.FLOOR AREA S/SQ.FT.
•'shad my s . used i s. 2'1 err eL�
pan J SIGNS ELECTRICAL l
d un
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
P
Fs 1 hereby effim[that I vat exempt Rm othe Contractors License Law for IM1e
1+131Lm 1,111—ingreasoa.(Sectioa]0315,Business and Professions Code:Any city an county TEMP.METER OR POLE INST.
O� which requires a permit to construct,alter,improve,demolish,or repairany structure
m} priermitsismance,also requires the applicant for such permit to file u signed statement POWER DEVICES
g) q0 that he is licensed pumuca mthe provisions of IM1e Chian? oYa License Law(Chapter
e.qo� 9(cnmmencing with Sec?ion]000)of Division 3ofthe Businessend Professions Code) SWIMMING POOL ELECTRIC VALUATION
Z. or that h7031.5 by any. plicarnd the basis far the alleged thedexompfion. exitny violation of 2�y, -tn
za or clam]is exeyanerefrommfor a crunixthbasis for
the exe cantina exit penalty of OUTLETS-SWITCIIBS-FIXTURES \`JJ
C not more than five hundred dollars(S500).
❑ Lnsowncraftheproperly,ormyemployceswith wageses theirsnlernmpensetiav, NGW RGSIDENTIALELECTR _SQ.FT. $'TORIES 'TYPECONSTRUCHON
y3r, will do the work,andthesvucmre isaotimended aroffereaforsalo(See,7044,Business
and Prefesucre Code:The Cransto 's License Law does sol apply to an owner of L
owere y wyces.pdsorimpraves(hereon,and ccesam ssuchwmk himselfor throaghhis
wer,thebuldup ,improvementhat such t
i,mld within
a Trended oroD'med ficarvthates.Bl OCC.GROUP RES.UNITS
huwevep the building or con of peat is sold within one year or i m rove f r t purpose
r-
builder will have the burden of proving that he did not build or improve for puryoee of O
,ala.). . . . . - ,
❑ Las owneroflhe property,am exclusively contracting with licensed comments to QTY. . 'PLUMBING-PERMIT' , FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions Code:)The Contractor's
License Lawdoesnot apply to an ownerofpropedy who builds orimprovesthefaon,and PERMIT ISSUANCE
amcomracts forsuch projects with a can0acmr(s)licensed pursuant ofhe Commodur's
License Law. ALTER-DRAIN&VENT-WAT[R HE - `PEE SUMMARY
❑ 1 sm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUT IDE FEES
NITARY Y_N
Owner Data DRAIN9-FLOOR,ROOP,AREA,C RECEIPTA
WORKMAN COMPENSATION DECLARATION CHOOI.TAX YN
❑ I herebyaffibe that l have a certificate ofeensenl to self-insure,or a cenifcaie of FIXTURES-PERTRAP RECEIPTN
Workers'Comporrica a Insurance oracerlified copy thereaf(Sec.3900,Lab C.)which PARK FEE Y N
covers all employee's under this pemt /� H / GAS-EA.SYSTEM-
Poll INC.40UTLHTS F.CE p
cy0 Gl0( Dlel SIGN FEES
Cut am, I GAS-EA.SYSTEM-OVER PLANCHECK
/ Cenififfuedy is bare y famished.
Cenilied copy is filed with the city inspection division. GREASEMSDUSTRL WASTE INTERCEPTOR GRADI
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE — I
to less. is series need not be completed([the parmil is Torose hundred dollars(5100) SEWER-SANITARY-STORM EA.200". ENERGY FEE i
I certify that in the performance oRhe work for which this panni?is issued,Isbell WATER HEATER W/VENT/ELECTR
sol employ any person in any manner so as m become.subject to the Worker' PAID
Compensation Laws of California. Dale _ WATER SYSTHM/1'RGTING Dvte ceiplk
Q zApplicant
'Z NOT'ICETO APPLICANT If,after making this Certifioateof Exeartarm,yaushould NEW RESIDENTIAL PLMB. SQ.IT. all TOTAL:
become subject to the Workers Compensation provisions ofthe Labor Code,you most
aforthwiW comply with such provi.ians or this permit shall be deemed revoked. BUILDING FEE b'
Ila la CONSTRUCTION LENDING AGENCY SEI S M I C FEE
O1 haehy affirm that there is a construction leading agency for the performnnea of the work for which this permit is issned(So..3041,Civ.C.) It ELECTRIC PEE e
Lenders Name
O U Lenders Address QTY.- ' ` ' MECHANICAL-PERMTT FEE, PLUMBING FEE
(�
I cert fy that I have read this applicaoen and slate that the above information is '
>i RW. correct.l agree to comply with all city and county ordinances and slate laws rclmingto PERMIT ISSUANCE MECHANICAL FEF.
E" ) buildingcrntararlim,and wrebynmhorize represemativesofthis city to onstagenthe A
U z shove-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)vgrce m save,indemnify and keep harmless IM1e City of Cupertino against
liabilities,jmgments,aost,mc1 expenses which may inaay wayacmue agninslsaid City AIR HANDLING UNIT(TO BLOW CPM)
ansequcnev o m g of Ibis per A /
7AIR HANDLING UNIT(OVER I0,00)Cold)mare A wU tshe ar Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Reccipsi
Will the a pplath nt or future building conamen area or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL
Code,Section 25532(a)?
2(u)4 11 No VENTILATION FAN(SINGLE Sam)
ISSUII CE DATE
Will thea applicant ormarm bulldln ccu tnsa BOILER-COME(311P OR 100,000 BTU) IpF'e
pp go pan egnipmem ordeviceswhich emit
aactions air contaminants as defined by the Day Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DiSV1C1? J
❑Yea ❑No NEW RESIDENTIAL MCH. SQ.FT. love
ry
1 have read the hazardous materials reyuirememe under Chapter 6.93 of the �N�1`.zV
California Health&Safety Code,Sections 25505,25533 and 25534. 1 nndvrstand that �'�� r`r V�
if thebuilding deer not eumemly have a tenon[,that it Is my renponsibiliry m nod[y the V
Ooccupant of the requirements which must be met prior m issuance of a CertlEcme of -
reapancy.
Ownerorautherized,mal Date
ISSUED By V IJ'�✓
OFFICE