28233APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO hit ILVING -ELECT RICAI.
PLUMBING C MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING
ING PROJOJECT IDENTIFICATION
PERMIT NO.
28233
BUILDINIG ADDRESS: ��F`///���/kkk�, kla.1�. 1F,.`y�as(��
l04179 �O"`
�/\'
SANITARY NO.
APPLICATION S/U�BMf/I'm, DA' IF.
`I 1 ,V\(YTaV
LOT#
L
OWN $fl't_MIi /s�Nq_qplgb
1`
COMI'RACfOR'S NAME: LIC NO:
NIC
❑
CONT0ROLII#
RCHIIECf/FisIGINEliR: LIC NO:
ADDRESS:
CONTACT: PHONE:
Q'I'Y. ELIiCIRIC PERMIT FEE
BUILDING PGRMIT INFO
BLDG ELX I'I UMIi MECH
PERMIT ISSUANCE
LICENSED CONTRACfOWS DECLARATION
I hereby affirm that I am licensed under provisionsofCTepmr9 (commencing with
APPLIANCES -RESIDENTIAL
Cy�SF/
JOB DESCRIPTION
Section 701M) of Division 3 ofthe Business and Professions Cede. and my license is in
PANELS
fail fmixelind-!eet.
Ll,cre ClassLica
UP TO 20AMPSI
Ihdc Commit,
201-IWUAMPS
ARCHITECTS DECLARATION
SQ. FI'. FLOOR AREA
S/SQ. En
OVER 1"AMPS
I uaden;an l my Plane shall he usc11 ac public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER-HUILDER
SPECIAL CIRCUIT/MISC.
I hereby r. from he Contractors License Law for the
that 1 nm exempt from Ire Comcast
TEMP. METIiR OR POLE INS'!.
exv and Prnfessiom Co city or county
followin n (Section 7031.5. Business
(Se
Baine, allh, In oo i
which itsiss a n permit to cathe alma Improve, demolish, nr repair any swment
its issuance. requires,meprovisicnntforsnchpurrintamrm to a se statement
POWER DEVICES
tpror hat be Licele
La
of the Conu sin's License law (Chapter
;nal ntra licensed P Sectio m Ne) of Division
9(coamnencing with Secaion]M00)of Division 3 o the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or Nal he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanl to a civil penalty of
OUTLETS -SWI'TCIIIS-FIXTURES
NEW RESIDENTIALELECJR_SQ. FT.
our more Nan Eve hundred dollars ($500).
❑ Lasowncrofen-powerty,ormYemployces with wagesas theirsolecomincromon.
STORIES
'I'YPF CONS'DRUCION
w III do Ne work, and the.stracare is not intended or offered for sale (Sec. 7044, Business
and Professions Cash: D , Conamenor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
own employees, provided that such improvements are not intended or offered for sale. If,
OCC. GROUP
RES. UNITS
.p
however, the buildingor improvement is sold within oneyearofcompletion, theowner-
builder will have the burden approving that be did nor build or improve for puryose of
sale.).
❑ [,aa ownaof the propcnY.am exclusively tomcatting with license] contranomm
QTY. PLUMBING PERMIT FEE
F1.00D ZONE
APN
Lns mer the project (Sec. A114, Business and Professions Code:) 11he Contractor's
icense Law docsnot apply In ppownerol'property whobuilds nr impnwes lhereer. and
PERMIT ISSUANCE
who contracts for such projects with ncnnuunons) licensed pursuum to the Cornerstones
License law.
gLTER-DRNN&VENT-WATLRIG)
FEESUMMARY
❑ 1 am exempt under Sec. , B & P C fa This reason
BACK ROW PROTECT. DEVICE.
OUTSIDE FENS
SANITARY Y N
RECLIPTis
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX YN
❑ Thereby affirm that l have ac-nilica¢ ofconcent loself-in.wre, ora certificate of
Workeri Comlwnsation Insurance or a ttnlilicd copyl,at,di See. 38M. Lab C.) Which
coven all employee's under this permit.Ops
Policy N
FIXTURES-PERT'RAP
1PARK
RECEIPT#
FEL? Y N
RECEIPT p
- PA. SYSTEM -1 INC. 4 DUTLE'1'S
BUILDING DIVISION FEES
Company
GAS- EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREASEJNDUSTRL WASTE INTERCEPTOR
GRADING FE -E
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OFIi%EMIT'[ON IL20Mir0_RKERS"
COMPENSATION INSURA`5�f,r.
(This section need not be cnmplemJ ifthe permitiii�ronellandred dollars (SIM)
or less.) �gc+� t C w1
I certify Nat in the performance ofac work for wNch Nis perm Iss dlltg�ll
-CRFASE'11iAP�'µ5'W
SOILS FEE
SEWER -SANITARY -STORM .21A1
ENERGY PEIi
W LE B 11.
not employ any person in any mapper so as to become subject Ne WWWWorkcrs
Compensation Lawsof Califomia. Dam
PAID
Dae ReceiptN
G
Applicant
-MeR
NE IDR TIAL PLMB. SQ. FT.
'OTA L:
NOTICF. TO APPLICANT It. after making this Certificate of Exemption, you should
becomesubject,,the Worker's Compenmt tunprovisioisof the Luton C, guowsl
fonhwilh comply with such Prov,knonrlhi.s permit dW' I M JeemcJrt bAi.SP.IC
BUILDING FEE
CONSTRUCTION LENDING A�NCY
SEISMIC P
Iherehy affirm lhanhem isaconsaructiun lending agetm}+$Ube gf{pppgtyeyj-
the Work far whichthis pmmit is named (See JM99. Civ. CJ
,r,�,���._.+--�
ELE '[
Lcndeh Name
QTY. MSCII IANICAL PERMITpGE
PLUMB F:E
lender's Address
1 vertiry date 1 have read this application and sante that the above infunnlacm is
erect. I agree to comply with all city and county ordinances and state laws relating w
PERMIT ISSUANCE
MF.CIIANICAI. I'di
huildingconslructinnand hereby authnriee representatives ofais city to enter upon the
imove-mer ioned prepeny for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCrI NTAX
AIR HANDLI NO UNIT (TO 10,00) CFM)
(We) agree an save, indemnify and keep harmless the City of Cupertino again#
Iiabildies.judgmems, costs and expenses which ma' in any waynccrucagainasnid City
onsaNwmxeaf cgrmti ofthi. mail.
/
AIR HANDLING UNIT (OVER Iq(XIM CPM)
EXHAUST IIOOD(W/DUC )
PAID
Sign Apt Connxra Dale
HEATING UNIT (TO UK," BTU)
HAZARDOUS MATERIALS DIS"CaRE
Date Rcc I#
HEATING UNIT (OVER 100,00DITU)
T TOL:
Will the applicant or future building occupant store or handle hismous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the koala, and Safety
VENTILATION FAN (SINGLE RISID)
-
Code, Section 25532(#)?
❑ Yes ❑ No
builAingnupvm use equipment nrdevlccs whiche+nil
Will thmtpplicnnt nrfulurea�
OWN'I'U) BOILER- COMP(311POR 100.
IIISjUbNCE DA' '
�sl
BOILER - COMP (OVER 100,000 BTU)
m; ndous air cnnanainams ns defined by the Buy Arca Air Quality Management
eN-O
fI.
{w
NEW RF_SIDENIAL MECH.—SQ. FT.
1390
Yea ❑ No
1 have ad the hcoadme, materials requirements requireents undo, Chapter 6.95 of the
mma
ty N g IJ119
.55
a�l Y
U!-
Californiaia health & Safety Code, Sections 505, 25533 and 25534. 1 understand that
if the building docs nal currently have a tenant, that it is my responsibility to notify the
ur
�Vf'Es 11 �N
IT 0
cepanl of the requirements which must he mat prior to issuance of a Ccnificate of
Occupancy.
ISSUED BY: J—✓=+=J
Owner or aahmrmd agent Date
TOTAL:
OFFICE