28130 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI LDING-ELECTRICAL PERMIT NO. 2813
8 1 3 0
APPLICATION/PERMIT PLUMBING-MECHANICAL . xV .jJ
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: fes! SANITARY NO, .APPLICATION SUBMITTAL DATE
1 ' Fag-S 1 UNIT# LOT# {� -
IiRS NAME: PI{ONIi:CONTRACTOR NAME: LIC NO:
8$ p N/C _J CONTROL
ARCH[[ECDENGINEER' LIC NO. �(4 ADD RES Elk.enJ U. C
CO A T: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT IN
(�" 370 �-S PERMIT ISSUANCE BLDG 171 ECT PLUMB MCCfI
1:1 ❑ ElP
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-
pa2 (hereby aflitm(haft stn licensed underpmvisiona of Chepter9(commencingwith RESIDENT IAL JOB DESCRIPTION
a1' 00 Section 7000)of Division 3 of the Business and Professions Code.and my license is in - PANELS
a W F full force and ef2ct /� r
<ZUY] 1,Icensuxs UP T02lJU AMPS
y6N Ua¢ Cnmm '�T ail cCTYCI 201-I"AMPS
1-K ARCHITECTS DECLARATION SQ,Ff.FLOOR AREA S/SQ.F(.
oz'3= I undersumd my plana shall be uxcdaspublicrecoN.v OVER I"AMPS
P w!=w SIGNS ELECTRICAL
Q,j J Licensed Professional
a
aQ OWNER-BUILDER DF,CLARA'I']ON SPECIAL CIRCU IT/MISC.
Oy0 1 hereby affirm that 1 am exempt from the Contractors License Law for the
413 n-cnfollowing mason.(Section 70315,Business and Professions Code:Any city ar count, TEMP.METER OR DOLE INST.
E'01 which requires a permit to construct.alter.improve,demolish,or repair any slmemre
C��� prinnnirsissuance,also rcyuircs the applicant l'or.euch permiuo filcasigned.aumman POWER DEVICES
yJ a�0z (hal he is licensed pursuant m the provision of the Conlmetees Licenm Law(Chapter
dkeLL 9(enmmencing with Section 7000)nf Uivisian3olNe Business end Professions Code) SWIMMING POOL ELECTRIC
VALUATION
that he is exempuherefntm and the basisfor the alleged exemption.Any vi.ini,muf
1-Za Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty Of OUTLETS-SWITCHES-FIXTURES
Epp
mol mom than five hundred dollar(5500). NEW RESIDENTIAL ELECH2 _SQ.FT.
aF_o ❑ I.nsowncrofthepropcny,ormycmployees with wagesaz lhcirsolecompensmion, STORIES TYPECONSTRUCTION
e, 22 will do the work,und the structure is not intended oroffcred(olsale(Sec.7014,Business
end Professions Cade:The Contractor's License Law does not apply m an owner of
property whobuildsorimproveslhereon,and whodmssuch work himselforthrough his
stn empinyecs,providcdahw such impmve..cnls arena lmm�ded err offercdfarode.It. OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofcompletion.lbeowner-
builder will have the burden of pausing that he did not build or improve for purpose of
sole.).
❑ 1,asownerofthepropery,amexclusivelycontmetingwiNlicense convacmnto QTY. PLUMBING PERMIT FEF.' FLOOD ZONE AI'N
construct the project(Sec.70a4,Business and purifications Cotler)The Contmcmr'a
License Lawdoes notapply coon ownerofpropeny whobuildsor improves thematicand PERMIT ISSUANCE
who contracts far-ch project with a commcun(s)licensed pursuant to the Contrecmr's ALTER-DRAIN&VENT-WATER EA
License Lay. ( ) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE O IDF,FEES
SANITARY Y N
• Owner Dale DRAINS-FLOOR.ROOF.ARFA.COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ (hereby al Hrm thatlhave ecenifieate of consent to self-insure,m ucenificamof FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance
eeoorr a certified copy thercof(Sec.3800.Lab C.)which PARK MEP. Y N
crs an
4yec udcry Ihigp I,S O GAS-HA.SYSE-IINC,40UTLETS RECEIPT"Policy"c's S=_9 / BUILDINGRECEI DIVISION FEES
C p y 6- a--Ig GAS-HA.SYSTHM-OVER 4(EA) PLANCHIiCK PHE
�❑ Ce ¢d copy is hereby famished.
ified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(TTissationneed not Fn completed if Ne permit is foram hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less)
I certify thin in the Performance Ofthe work for which this permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the Worker' PAID
zCompensminn laws of CaliLsmia. Dam WATER SYSTEMfFREATING
Applicant Date Rccciplp
0
z 2 NOTICE TO APPLICANT:TL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
EI become mbjen to the Workers Compensation provisions of the labor Csde,you moat
> fonhwith comply with such provisions Or Nis permit shall be deemed revoked. BUILDING FEE
per, CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that hem is a construction lending agency for the performmnce of
U O the work for which this permit is issuedSed.3097.Civ.C.) TOTAL: CE
Lenders Name
ULender's Address QTY. MECHANICAL PERMIT FEE E
} Lk1 1 certify that I have read this application and smrt Nal the above infommtion is
correct.I agree m comply with all city and county ordinances and slate lawa relining to PERMIT ISSUjTOMECH.
FEEbuilding construction,and hereby authorize representatives ofNiscity to enter upon the
U 'z Movcmvmtioned pmpmty for inspection purposes. ALTER OR AN'PAX
(We)agree to save,indemnify and keep luumless the City of CuEminn against
liabililies,judgmemv,costs and expemes which mayinanywayaconagamassid City AIR HANDLI , CFM)in co smryeccof the graming of this permit.
AIR HANDLICFM)Signature ofApplicarYConlrselor Dae EXHAUSTITPAID
HAZARDOUS MATERIALS DISCLOSURE ) Date Receipt#
Will the applicant m future building occupant store or handle hazardous materialas defined by the Cupertino Municipal Cade,Chapter 9.12,and the 11.111,and Safccy A' NG UN '1'U) .A
Cade,Section T5532(a)P
❑Yes El No VERTILATIONP INGLE RESID)
Will theupplicanl orf' builJingmcupam useeyuipmem err devices which emir
BOILER-COMP(3HP OR 1MJX)0 BTU) ISSUANCE DA'Z'E
hmaldaus air comvninanls az defined by the Bay Are Air Quality Management BOILER-COMP(OVER IIMOEX 'IV)
Uisvicll
❑Yes ❑No ERMIDENTIALMECH.1 have mad the hazuNaaz materals reyoim.tras under Chapter 6.95 of the
C,d
iflh b a Safe - y ho,d rem 255(1 onit is3 yresponsedd I undomNnd chat
ifdi uiltlmg slyM1avears 255that is ix a responsibility rot nn'y theIX and Of Jia Rx�Ed Itch must be met poor to Iaau➢nCC 9 Gell ale O ns'o a7Elall ander, aapp 1 Date : ISSUED L
OFFICE Lrta