28165 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO B ILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PIAMRING-MF.CHANICAL 28165
BUILDING DIVISION NUIIAING PROJECT'IIIEN'fIFICAT'iIIN
BU DINGADDRESS: SANITARY NO. APwPLICATIOONNSUBMITTALDATE
1 1 4-UX-0 n4wY UNITN LOTp V
O NIRS AME sSP�Nr.�4-2 C NTRA��NAI� IZ��� CCCCJJJJ
1_`\I NIC CONTROL4
ARCHITECT/ENGINEI:R: LIC NO: D�S: c ❑
CONTACT: S r ONE: BUILDING PERMIT INFO
�OsQTY. ELECTRIC PERMIT FEE
G BLDG ELE PLUMP 1EC1
PERMIT'ISSUANCE
LICENSED CONTRACTOR'Sions cf hapmT9 APPLIANCES-RESIDENTIAL �r �_ t.r OEC ryN —�
pmZ Ihcrcby affimrlhallum licensed under provisions ufChapmr9(commencing wllM1 rpTy^ /.i/ \.LI[i'1J
00 Semimr]INIB)mf Divisi�n3nf,hm Businen and Pro(p&sinne Coda onJ mylicense is in PANELS v`_ \
m{- full forec and effect. p / ,
Qj� License Cl Lic, Z—( S UPTO200Ah1PS
F_6Oo Dam Coniractsn I C/ 201-1000 AMPS
F yZ ARCHIT'ECTS DECLARATION
SQ,1-7.FLOOR AREA E/SQ.ItI'.
'GOriY- Iunderslandm I hll be used av blit rcands. OV17R 100)AMPS
CZ-121 ypanes a pct
F,y F m SIGNS ELECTRICAL
QyF Licensed Professional
�xai< OWNER-BUILDER DECLARATION SPECIAL CIRCUFDMISC.
KO a U 1 hereby affirm,hal 1 am exempt from the Connachms License Law for the
u1 B W Ot following reason.(Section 9031.5,Business and Professions Code:Any city Or county TEMP.METER OR POLE INST.
C< which mercies a return to construct,alter,improve,demolish,or repair any scheme
prior m its issuance,also requires me applicant for such Permit file a signed matement POWER DEVICES
K<O ,hal Be is licensed puament to the provisions of the Contractors License Law(Chapter
t'.-E MW 9(commencing with Section 0000)of Division 3 ofthe Business and Professions Code) SWIMMIN PO .ELECTRIC VALUATION
LL orthinhei,excmtiherefrnmandthebasisfonhcalle Je,emt An It f 2�o ODo
W—ve P he Pion. yvimaiono
F-ZQ Section 7031.5 by any applicant for upernit subjects the applicant toacivil penally of 'I'LIH' -S 'CI -FIXTURIiS � f
=p not mom than two hundred dollars(S500). NE F, -L E SQ.FT. STORIES 'IV PE CONSTRUCITON
WL: ❑ 1.asowncrofthe prnper,y.or my employees with wages as theirsole compensation.
a3=n will do the work,and lhesuucture,ianm intendedoroffered fimsale(Sea 7044,Business
and Professions Code:Fie Cocotte,License Law does not apply hr an owner d
property whobuildsor improvesihereon,and whodoes such work himselformonouh his \
own employees,provided that such improvements arc not intcndWoro(fined forsale.If, ` \ FICC.GROUP RIS.UNITS
however.the building or improvement is sold within one yearofcomple,ion,,heowner- \ \ �—
builderwillhavetheburdenofprovingthathedidnorbuildorimproveforpurposeof \ '
❑ [,asnwner of the Pnrpeny,em exdu,ivcly emmmaing with tiro edam cianx us QTY. PLUMHINO PER 'f PEE I1.00DZONE qPN
consumer the project(Sec.7044.Business and Professions Code:) [be Contractors
License Law does not apply to an owner ofpropery who builds or improves thereon,and PERMIT ISSUANCE \ ,
who contracts for such projects with a contractors)farmed pursuant o me Contractor a
Liters,Law. ALTER-DRAIN&VENT-WATER UtA) FEE SUMMARY
❑ 1 um exempt under Sec. .9&P C for this.,on BACK FLOW PRO'I'ECf.DEVICE OUTSIDE FEES
SANITARY Y N
Owner DateRAT DRAIN FIDOIC'HOOF:dR .GOND. RECEIPI'p
WORKMAN COMPENSATION DECLARATION �h-'.- SCHOOL TAX YN
❑ Ihcrebyaffirmthatlhaavcamorconsemto self-insn r�a,{SrtitmelgoC' FlSTURM-PER TRAP r RECEIPT
Wmrtrn'Cnmpensmion lnsu..ce ueriacenified wpy ttlLub CJ which s PARK FEE Y N
Polson Xllcmplmyca'&ander this pemtit. GA9 EA.SJS I INC�4ourh_3'rs R EIPTM
y BUILDING.tly O ITFS
Company ' .. GA5.LA.vS.YkT VER4(FA{ PLANCIIIiCK FEE
❑ Ccnifiedcopyishembyfumished. ��
❑ Cerified cmpY is Elal with the city in&pectnn division. GR
t { IiA5F71§DH5 L ASTE INTF.HCF,PI'OR GRADING PTB
CER"I'H ICATE OP EXEMPTION PROM Wo ler. AC i'1' SOILS I'
COMPENSATION INSURANCE
This section need no,M completed True permit is formic hundrg Alft,s(EI00) : -SA RY-STORM EAA100FT. ENERGY E S
orhi ) lf:'' UU
I certify thtin' thpert f,he kr hitt rO._ t issued,l M1II WATER HG"f�j WNSN1`R!f,F�.CIA
not pl Y Y C Y mr I 1 I IIS Wy clw PAID ry h
Cmmpe :t nn Lawsof C hf Doc ,:.wen^r' icor +-b ' WATT R SYSTEM/IREATING Date R c- 1 v
zO NOTICETO APPLICANT:IL after making this Ccmficam of Exemption.you should NEW RFSIDENTIAL PLMB, SQ.FT. TOTAL
ice. become subject o the Worker's Compensation provisions of the Labor Cede,you must
7 form,iso comply with such provision.or this permit nhall Is,deemed invoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE K�
Z I herebyarfirm thin there is a ementumio,lendingagency fomhe perf.rom.met
U O the work for which this permit is issued(Sec.3097,Civ.C.) T ELECTRIC FEE
Lender's Name
u-' F Lender,Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 eeeify,hat I have read this application and smile Thal the aMve information MECHANICAL FEE h
mmect.I agree m comply with all city and county ordinances and&him laws relining in PERMIT ISSUANCE i+
buildingemearruction,and hereby aatMrim representatives of,his city inciter upon the
U Z aMve- CONSTRUCTION TAX
mentioned property for sonify ad keep F.r TER OR ADD TO MECO
(We)agree Iso sive,indemnify unit keep harmless the Ci ly nr Cupertino again,t
Iiabilitic,,juJgmcnls,cp&I&and cnpenscswhlch mayin any way accruengain,l Said City AIR HANDLING UNII'(TO I00NI CIrM)
in cars /7 999uuu ��gee of dr,grunting of this permit.
1ZJuylp AIR HANDLING UNIT(OVERIQWOCFM)
Sig awrc of pplicnnpCon� Date 77 EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('r0 too I)BrnD Date Receipt p
Will the applicant or future building occupant store or handle hvzrJnus material HEATING UNIT(OVER 100,00g)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
1111111,
Code.Section 25532(x)7 VENTILATION FAN(SINGLE RIiSIDI
❑Yes ❑No
801LF.R-COMP(3I{p OR IOO.IXN)B'1 ^' /i
U7 A iS$�UANCE DATE
Will the applicantnrequipmentfuture buildingoccupan,use equipment ordevices whichemil tl'
.� 'hazardous air co staminana as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District, JUN 12
❑Yes ❑No NEW RESIDENTIAL MTCH. SQ.F1'. 1('9
aJ�O5
1 have read the harardous materials requirements under Chapter 695 of the i LLa
California I b ahh&Safety Code,Sections 25505.25533 and 25534.I understood that I vl' (PUPEHON
if the building does noel enormity have a tenant that it ix my responsibility m notify the O
recupunt of the requirements which must M met prior to issuance of a Certificate of
Owup:mcy.
Owner or authorized.,cm Doc TOT ISSUED RY:
OFFICE