28085 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL p O p C
BUILDING DIVISION BUILDING PROJECT IDENHFICATION O OJ
BUILDING ADDRESS: I��p\//�� �` •�_....,, SANITARY NO. APPFUCATION SUBMITTAL DATE
— _ ` NNN(�ppp �/ /� UNIT# E��J�. //�'� L%OTT+#^ o
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HO�1 oqt RA OR' N6 1 /Vkf 1.1 LIC P.19��' .J ...JJJ
J NIC COM'ROL p
^• ARCHI✓TECI'/ENGINEER: LIC NO: ���� �� O �f�� ^� C ❑
CONTACT: PHONE: VF J
QTY. ELECTRIC P MIT FEE B BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMIT ISSUANCE El ❑ El
LICENSItCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OKZ Ihcrcby aflimuh:nl:un licensed underprovisionsofCM1apmr Y(commcncing wish J06 DESCRIPTION
WOO Sect lon]Ig0).f Uivision3 nl'me Ruvinexe and Professions Cole,and my license is in PANELS � ���
full force and cffcc't. pp
UU T.l UP TO 200 AMPS '
L sr c1
License Class Lic#
m Qvai Dam mCTSD 2(II-IIXIO AMPS
5 OT S(]��FLOOR A S/SQ.IT.
ZFONZ ARCHITECTS DELLA ION OVER II100 AMPS /•/1 � ��
OZ_❑ lundernanJ my plans shall be mounds,
as public mcos. YVSLJ
p'm F m SIGNS ELECTRICAL
<"5-'j Licensed Professional
y=6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyU I hereby affirm that 1 not exempt from the Contractor's License Law far the
m�OvFi following renwn.Section 7031.5,Business and Professions Code:Any city or county TIME.METER OR POLE INST.
which requires.pennino construct.Iter,improve,demolish,mrepair any, uaure
,W}7m itxissuance,alsorc msrhea licant for such uo fileasi ed.amment POWER DEVICES
prior yui PP permi gn
uK�p that he is licensed pursuant to the provisions of the ContrazmC s License Law(Chapter
dd„K 9(comndncing with Section]000)of Division 3 of the Business and Professions Cute) SWIMMING POOL ELECTRIC VALUATION
a
or he is exemptherefrom and the basis for the alleged exemption.An violation f
W=mR pian. yvioai.n. OUTLETS-SWITCHES-FIXTURES
FZQ PotSecon 7031.5 bymthniv any hundred
dollars($50nt for a 0). subjects the applicannoacivil penaltyof
�S7 not more than five hundred Joll:us(5500). NGWRESIDENTIALELECR SQ.FT. STORIES TYPE CONS I'RUCTION
z t—o ❑ I,asowncroftheproparty,ormyemploywswimwagesmtheirsolec=Nmation,
willdo the work and the saumurc is not mtendedoroffered forsale(See 7044.Business
and Professiom Cale:The Contractor's License Law does not apply to an owner of
property whobuildsor irproves thereon,and whodoes such work himselfor through his
ro l.yws,p.nvided Nmyuchimpmvemems arenoUmentled ondfmulf rsalc.If. OCC GROUP RES,UNITS
however,lila building or improvement is sold within one yearofcomplGion,the owner- 1 �-
builder will have the hurdun W Paving that he did not build or improve for pmFoxa it -
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ t.......
construct the project(Sec.7044.Business and Professions Cale:)The Contractor's
Liccnsc Lowdown.xpplywan ownerofpropcny who builds orimproves thereon,and PERMIT ISSUANCE
whocontmds foesuch projects with aconuucards)licensed pursuant to the Conuaemrs
License Law. ALTER-DRAIN&VHNT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT#
•
WORKMAN COMPENSATION DECLARATION DRAINS-FL AREA,COND. SCHOOLTAX Y N
❑ Ihcrcby affirrn that lhrveacenificam of consent to self-insure,oracmificate Of I'
P RF,CF,IPI'#
Worker Compensation Insurance or a certifiedcopy thereof(Ser.3801.Lab C.)which s PARK HE Y N
.all employees under this permit. AS-EA.SYSM- .4 S RECEIPT'#
cove
Policy# BUILDING DIVISION FEES
Company GAS.EA.SYSTEMOVER4(EA) PLANCHECK FEE
❑ Certifcdmpyi.herebyfumished.
❑ Ccnifcd ropy is Bled with the city inspection division. GREASUINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is furore hundrul dollars(S 100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or Iws)
I cen ify that i n the perfommnce of the work for whichthls permlas i...ed,l shall WA'PER HEATER WNENT/ELECTR
noI employ any fiIn any manner sit us l ebje.l t0 the Workers' PAID
Compensation L. ,v.)California. Date T� A�— WA'I HE SYS IEMOTEAI'ING Date Receipt#
Oz A lican.�P�.�/—fn—w+/—�eglo )tom
z 0 NOl'ICE'10 APPLICANT:If,after making the Certificate of Exemption,you shouldNEW RESIDENTIAL PLMB. SQ.FE TOTAL:
Cn become subject..the Workers Compensation provisions of the Labor Cale,you must
7 forthwith comply with such provisionsn
or permit shall be deemed revoked. BUILDING FEF,
A 61
0. [] CONSTRUCTION LENDING AGENCY SEISMIC
I hereby affirm that hem is a construction lending agency for the performance of
U O the work far ishich this permit is issued(See 309],Civ.C.) TOTAL: ELE 2199
E
Lender's Name
Ll. F Lender's Address QTY. MECHANICAL PERMIT EEE PLU FIiF,
O J 1 camify tb.I have read.his application and nate that the above information its L tdy �csa1L y
correct.IaCree m comply with all city and county ordinaries and.state laws reading m PERMIT ISSUANCE - W�YT'-N0gi1 LHI�N�
F' (n buildingconstmction,and hereby au.hodm repmsenNrves ofthis city master upon me CONSTRUCTION TAX
O Z above-mentioned propcnY for inspection purposes. i ALTER OR ADD TO MECH.
.-. Cier)agree.o.save.indemnify and keep harmless me City of Cupertino against
liabilities,judgmems,cunsundexpemeswhich may m y way,accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
I �.�t�g��o1/f this pe
e eIv Wes/ 7A ✓— U rAh AIR HANDLING UNIT(OVER 10.000 CFM)
Sigru�caPOCmu.aor Daft, EXI IAUST HOOD(W/DUCT)
PAID
I IA'/.ARDOUS MATERIALS DISCLOSURE I IEATING UNIT('1'O 100.000 BTU) Data Rmcipt H
W ill the applicant or lutme building occupant store or handle haaurdom material IIEA'1'INO UNIT(OVER 100,000 BTU) TOTAL
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Gale,Section 25532(25)^
0Yes C3 Na VENTILATION FAN(SINGLE RESID) 1
RAFE DAl'F;
Will M1e applicant or future building occupant use equipmentordevices which emit I BOILER-CONE(3HPOR 100,000 BTU) pp 1 Pq
hauMous air conalC3minants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00U BTU) MAY
1 1 199J
•
District? Ycs ❑No NEW RESIDENTIAL MECH.—SQ.FT. MAY
1 have real the h...nkma mated d,replud emems order Chapter 6.95 of the GI ry Ur GUYth I INV
California Health&Safety Code Sections 25505,25533 and 25534. 1andernand mat
if the building dos not currently have ate am.that it is my responsibility to notify the
occupant of me myuircments which must be met prion.issuance of a Cerificme of
Occupancy.
mp
Owner or milmin ed age. Doc TOTAL: ISSUED BY:
OFFICE