28263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B u.Ul G.ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PI.UMBIN;-MECHANICAL np L+
BUILDING DIVISION I{UIh If ';PROJEC'I'IUEMIIFICATION LO U
BUILDING ADDRESS p ,��f SANITARY NO. APPLICATIONSUBMITTALDATE
99si44e M UNIT# LOT It
OWN/�iS NAMf;: PHONE: CO RACfOR'S NAME: L( LIC NO: 1
H S �. 1 M#JI. V C O 1 NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: '' PHONE.: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PFRMI'I ISSUANCE El
CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL -
1 0 IhembyafElm that]am licensed under Flrovisions of Chap¢r9(commencing wish I • TOB DFS IPTI .
U 2 Scttinn]000)of Division3 of the Busiress and Profossions Code,and my license is in PANES
CUF full force and effcc /
azul License Class___t�3_eL Lic.# IO Vol Vol UPT0200AMPS
y Q y Dale Contractor 201-1000 AMPS
F'z ARCHITECTS DECLARATION OVEN 1000 AMPS SQ.FT.FL AREA S/SQ,FT
ZO'OG N O l understand my plars shal l be used as public records.
F,In F w SIGNS ELECTRICAL
Qy Licensed Pmfexsional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oi0 I hereby affirm that I am exempt from the Contractors License Law for the
W 3 W in following ressoa(Scmimn]03 L5,Business and Professions Codo:Any city meeumy TEMP.METER OR POLE.INS 1,
F'•O J which requires a Permit to construe,alter,improve,demolish,or repair any structure
� Y� prianni.issuance,alio requires lM1<applicanl Grrsuch permit to GleasignW smmmem POWER DEVICES
y4'j C p that he is licensed pursuant to the provisions of the Convectors License Law(Chapter
44oLL 9(<ommen<ing with Semion]0(M)1 of Division3 of the Busincss and Rnleaions Cade) SWIMMING POOL ELECTRIC VALUATION
WMm or that he is exmmpnhnrefmmnmv1 the basis lin the alleged exemption.Any violation of
FZ¢ Section 7031.5 by any applicant for miapplicant a pert subjects the applicano a civil penalty of OUT -SWITCHES.FIXTURES
ASO not hose
Lasavorofthmdmdrry,orroyero). NEW RESIDENCALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
CFS ❑do
wrk.adthespecy,nrmyempendeeswed offemd wages frsalei(Sole compensation,
will dothe work.:mdthe he Contratructure is ctor,
Licenseawduernsele(Sly In an,Business
and Professions Ctdc:apr Cnrvenda.and
Law does nal apply fi an owne is
prnpcny whobuikksorimpmvcslhctcan.and whodces such workhimulfor through his
employecs,pmvidM Nm such improvememsarenotintended oroH<re4 forsale.
If. OCC.GROUT' RES.UNITS
however,the building or improvement is sold within one year ofcompletion,theowner- TOTAL
builder will have the burden of proving that he did not build or improve lin purpose of
sale.).
❑ I,as owneriftMpropery,anexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7614,Business and Professions Cade:)The Comreeor's pERM1 SUANCF,
License Law does not apply torn ownerof property whobuildvorimprovevhdmmo i
who comraus forsuch p..jecu with rcontmmnrd)IicersW Puouamu.the Cn ewes
License Law. ALIER-D AIN&VENT-WATER(EA) IEE SUMMARY
❑ I#m exempt under Sec. .B&P or this onown BACK FLO ROTECT.DEVICE SANITARY OUTSIDE II�F_S N
Owner a¢ RECEIPT'#
DRAINS-FL( N,ROOF, COND.
WORKMAN COMPENSATION OF .ANATION SCII001.'1'AX Y N
❑ Ihcmby affirm that]have rcenificatecate ofof cone Iose'psed.re.0.1.1, )which FIXTURES-PER RAP RECF,11'Tp
Workers Compensation Insurance uracenified cop Nttrof(Sec.JBOO.InbCJ which PARK FLE YN
covers all employee's under this p draft CAS-FA.SYSTEM- INC.4 OUTLETS RECEIPT'p
Pol y# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-O ER 4(EA) PLANCHECK FEE
❑ Ccnifiedetpyishembyfumishcd.
❑ Cedified copy is filed wiN the city i['A
vision. GRGSF/IND RL SIti INTERCEPTOR GRADING FEE
CHR'I'IFICATEOFEXEMOMWORKER.S� GREASE AP SOILS ITH
COMPENSA'PINCE
Mix sermon need not be completed isf one hundre 11 ) GR-S NITARY-S ORM G.2001-7. ENERGY FEE
or less.)I certify that in the Performance of thhich ii blATERHEATERW/VE l'/FLECTR
ml coup, any person in any m ero ct la Ixsu t kel� PAID
CompenationLawsofCeliffeari(DateATER SY AND Date Receipt If
O z Applicant
z NOTICE TO APPLICANT:If,after makinj this Certificate t emption,you should IDF:NTIAL PLMB. SQ.FT. TOTAL:
ti become subject to the Workers Compensati mpnrvisions oft Tabor Cade,you must
forthwith comply witbsuch provisions or if is pernat shall be deemed revoked. BUILDING FEE
HJ SEISMIC FEE
0. Q CONSIRxa onsh L'N I d AGENCY
1 hereby affirm that there is a cnnswe'nn lending agency for the performance of
U z' the work for whiab this permit is issucd(Se 3097,Civ.C.) ELECTRIC FEE
Lender s Name PLUMBING FEE
F Lenders Address It QTY. MECHANICAL PERMIT FEE
U 1 certiry drat I have read IM1is appRead n nd stat¢that the above i rmation is
MECHANICAL FF.F,
�" W coraco. lagreemcomPlywithall ciy and count ordinances and stat smlating to PERMIT ISSUANCE
F' building coronation,and hereby uulhoriu mpresmiivuxaft ' ymemer upon 0e
(� 'Z move mentioned pmpcr Pcen for ins At.]HE OR ADU'IO MECII. CONS"INUC{'ION TAX
ron corpuses.
(We)agme m love,indemnify end keep harmless the City of Cupertino against
liabilides.jedgments.cos.and expenses which may in any otyricermit,mmi,aid City A IR HANDLING UNIT(TO 10,0110 CFM)
in consequence of the granting of this permit.
— tea .��2 `Q� AIR HANDLING UNIT(OVER I0,11W CFM)
Signore Applicaro Comfde� /Date EXHAUSTHOODOVMUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I0g,00)BTU) Date Receipt#
Will by applicator orofuture Munbuilding de.Cam more or athandle hazardous material
as defined by the Cupertino Municipal CMc,Chapter 9.12,and the Health and Safety I HEATING UNI"1'(OVER 100,000 BTU) l'O'IAL:
Calc.Section 25532(e)?
11 Yes ❑ No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the applicumorfuwrchuilJingoecupunmsceyuiement ordeviceswhich emit BOILER-CONIC(3I{p ON 100,000 BI U)
hazardous air comeaminam as defined by the Bay Ana Air Quality Management BOILER-COME(OVER I01).000 BTU)
District?
❑Yes ❑No NI?W RESIDENT Al,MECH.—SQ.FT. P q ' D
re
I have ad the hazardous materials tequimmen.under Chapter 6.95 of Lha /x6
California Health&Safety Cale,Sections 25505,25523 and 25534.I understand that JUL
if the building does not currently have a whom,that it is my msponsibility to modify the 2 6 19
rccupm m aof the requirements which must be met prior issuance of a Certificate or
ar
Oarprney.
Owneroraiffimr edagcnt Date TOTAL: ISS
OFFICE