28432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ONCUPERTINO BUIL)INIs ELEC I RACAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIHNG-MECHANICAL 28432
BUILDING PROJECT IDENT'IF'IUA'FION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2 1 @MAE. LOT#
.OW iR A E' L CON A M I LICNO: I'
N/C CONTROL#
RCHITEt TOHNGINBFR: LIC ND; ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, LOB DESCRI N
Z=z Iherebyaflirm that l unlicensed underprovisionsofQatpser9(commencing with
WOO❑ Section T00t Division 3 of Ne Business and Professions Code,and my header is in PANELS �/J�''��{�
=�E full force and effect. UP T0200 AMPS - - L 1'
F<Z, License Class Lic.N
FyF-...<y Dam Contractor 201-10110 AMPS
Z8r-E; ARCHITECTS DECLARATION OV ER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.PT.
O Z qqq I understand my plans shall ba used as public records.
FN SIGNS ELECTRICAL
�j Licensed Professional
C pxd OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
ey�'O V IngherebyMas dgmn that I am exempt from she Co Professions
Co License Law for the
tv1'�i4N
which
requires a.lgmion 90]1.5,Businessand Professionsh,or Any city or county TEMP.METER OR POLE(NST.
whichrequiresnPermit touirestealter,improve.demolish,or repair any swment
Y�
poor to its icernd also
nttoteprovisionsocant forsuch theCopectorsLicesigned eLaw(mnenr POWER DEVICES
tB G O than he is licensed pursuant to the provisions of she Contractors License law(Chapter
a Mto 9lhat(commencing emit tSectionT000)ae basisionJohhe Business and,Any vans Cade) SWIMMING POOL IiLECTRIC VALUATION
_,y S.r a731.5hlat,rip,omand sha basisforthedlegedexemption.Anylperionof -
FZQ Section OOose riv anyapplic.liart apennit subjenuM1e applicant toecivil penalty of OUTLETS-SWITCHES-FIXTURES
g lm ort slum Bvebe pont dallms yempl NEWRFSIDENTIALELECTR S .IT.
p wd Lasownernfthepropaclum isnot
yempinded withwagesasalages.le 0,PL Business Q STORIES TYPE CONSTRUCTION
L will dmhewons ande Tic Contractors
La a doesd s
applytA154,Business
and Professions Code The Comraesar's License law does nos apply to on owner of
progeny whobuildsorimpmves thercon,and whodas such workhimselforthavugh his
own cmployees.provided thatsuch improvements on not intendedoroffered forsole.If. OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yenrofcampletion,theowar- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale)
ownerof the propeny,um exclusively contracting with licensed contractors so QTY. PLUMBING PERMIT FEE ROOD ZONE APN
r1,..
the project(Sec.7044,Business and Professiam Cade.)The Co itmcmr's PERMIT ISSUANCE
mets forsuch pmjcns with accoutrement)licensed pursuant to the Connector's #ITER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Lew.
❑ 1 am exempt under Sec. ,B&P C for Nis rtaun BACK ROW PROTECT.DEVICE O SDE E
SANITARY Y N
Owner Dote DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercby affirm thatlhave ucenificma ofmnsentmulf-imme,ora artificau of FIXTl1RE5-P RECEIPT#
Worken'Compenosdon Iuurance ora certified espy thereof(Sec.3800,Lab C.)which PARK FEE Y—N
-
coven all employee's under this permit. GA A.SYSTEM-1 INC. ETS ` RECEIPT#
Policy# K BUILDING DIVISION PEES
Company GAS-RA.SYSTEM OVER 4 HLA) PLANCHECK HE
❑ Certified cape is hereby furnished.
❑ Crnifled capy is filed withthe city inspection division. GREASE/INDUSTRL WASTE INM-RC OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'rsu�j
GREASETRAP SOILSFEF.
COMPENSATION INSURANCE 41,
(Thissection need not be completed ifahe permit is for one hundred SEWRR- A A Y-STO 200 ENERGY PER
mless.)
I certify that in the performance ofthe work for which this permit iWAT' W/Vt
na employ day person in any manner m m m became subject m PAID
Compensation y person
. Dam A - Y NG Doc Receipt#
0 z Applicant
z NOTICE TO APPLICANT:If,aBar making Nis Cenificnm of Exemption, nu should NE 0.PS L LMB SQ.FT. TOTAL:
r� become subject to the Worker's Compensation provisions of the Labor Cod,you muss
FFa 'r forthwith comply with such provisions or this permit shall be dttmedreao BUILDING FEE
SEISMIC FEE
(� CONSTRUCTION LENDING AGENCY
z I hereby affirm that hem is a conshasion lending agency for the per, once of
O the work for which this permit is issued(Sec.3tN7,Civ,C.) ELECTRIC FEL'
Lenders Natne
OU Lenders Address xx QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify than I have read this application and stale shat the above manscr alum MECHANICAL EEE
0. correct.l a gree to comply with all city end county ordinances and state laws relating to FRMIT ISSUANCE
building construction,and hereby authorize representatives of this city to enmrupon the
U z ubrwe-mentioned property,for ins tion purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(We)agree save,i e and kap harmless the City of Cupertino against
liabiliti 'udg c t dm panto ich mayin any way acemeagainst said City AIR HANDLING UNIT(TO IO."CFM)
an en a b fthis it.
AIR HANDLING UNIT(OVER 10,00)CFM)
I
Sig t
tam&AWlikanConanalor Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MA g occupant
DISCLOSURE
IiGTING UNIT(TO 100,(100 BTU) Data Receipt#
Will sheee Culnwrfuture Munivi ldingoccupamstore,9,o.and le the
dous h add Safety
HEATING UNIT(OVER 100,000 BTU) TOTAL:
ll
as defined by she 32(a)?ino Municipal Cwle.Chepuer 9.12,end the Health and Safety
Code.Section 255J2(a)T
❑Yet 12 No VEM'ILATION FAN(SINGLE RESID)
NCE DATE
^
Willtheeppliwnlnrfumrebuildingacupantuueyuipmenundevices whichcmit I BOILER-COW(JHPOR 100,000 BTU) 4/�^ 1109
W
hvardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IM."BTU) ' O
Duvict? G
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Fr. H LLN 7g9s
I have read the hazardous materials rc9uircments under Chapter 6.95 of the t/I✓ S
California Health&Safety Crude,Sections 25505,25533 odd 25534.L understand Net
if the building does not currently have u mmmn that it is no,responibility to notify the
occupant of the accouterments which muss be met prior to issuance of a Certificate of
Occupancy.
Omar or euthniud agent- Dam TOTAL: ISSUED BY:
OFFICE