28298 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ a.x ^ ^ w
BUILDING DIVISION APPLICATION/PERMI'P PLUMBING-MECHANICABUILDING PI IECI'IDENfiFICA'i'ION L. L yV( L�JJ lyJ(
JUM.DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL"DATE
N SONAMF.: PHO F.: CONTRACTORS NAME; LOT# LIC NO:
!J _ p T/ y O NC CONTROL#
".JH
R.I II'I :C9'/ENGINE L' LIC NO: ADD412 C L r D�T�a / ❑
CONTACT: PHONE: R /
QTY. I3LIiC1'RIC PERMIT FSE BUILDING PERMIT INFO
Oh�p �MP (��i-JT Z�33Z PLUMB MECII
PERMIT ISSUANCE BL C
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
O=Z I hereby affirm that l am licensed underpmvisiomofaapter9(commencing with JOB DESCRIPTION
WOOSenion]OW)of Division3of the eusinw end Professions Cale,a it ylicenuisin PANELS
FyV full Wrceundeffect. 12
GG UP TO 200 AMPS
zz hicenseCas L
y 6 Da¢ Convector 201-10110 AMPS
Z FO rNi Zrl a �— ARC]IITECI"S DECLARATION OVER IOW AMPS SQ.I>f.ILGORAREA 8NQ.Pf.
p m F 1 unJcrsmnd my plans steal be ms.
eA as Aute]Ic record
SIGNS ELECTRICAL
EXW—j LianscJ Professional
�, < OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
%0 p2 1 hereby affirm that I and exempt front the Contractors License law for the
W 3 W y following Teuton.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
L�'ON 5 which m]mors a permit to contemn,ale,improve,demolish,or monitory etmcwm -
:;I{ i In-,to it,issuance,also oupirev rlipplicant for such permit to filevsigned tenement POWER DEVICES
_ p the he is licensed!pursuance the provisions of the Commetors License Law(Chepmr
aao�' 9(commencing with Section 70)(0)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALLA TION
❑,� nnlun he is exempnherefrom anA the heir fnnbcaReged exemption.Any violationof OUTLETS-SWITCHES-PI%TURES /
GSection 7031.5 by any applicant for a lanmit s Ihjects the applicant to a civil penalty of
oo more lhun five hundred dollara($500).
❑ I,vsowncrofthepropcny,onnyemployeuwitb wvgee aetheirsolecamlmnsut...r' NEW RESIDEN'I'IALELECfR _SQ.PI'. " SIORIER TPECONS'I'RUCHON
O.ii:L will do the work,und the svucwrc is not inlcnJalarolTared(creole(gec.7f44,Buainess /v'7-r
and Proossion,Code:The Contractors Licenm Law does not apply to an owner of
pmpcny,whobuildsorimproves themon,ana whodens such workhimuBormanughhia
cmpinyux,provided Nassuchimpmvomente um naimended orofrercJ foraele.If, OCC.GROUT' RES.UNITS
however.the buildingorimpmvement is sold within one yesrofeampletion,meowner- T
builder will have the burden ofproving that he did not build or improve for purpose of
sale.).
❑ I,asnwnerofthepropeny,ameaclusivelycommctingwiNlicenudcontmetorseo QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lnsumer the project(Sec.7144,Business and Professions Code:)]he Contractor's
icense Lawdoes notapply to an ownerofpropeny whobuildsorimproves themnn,und PERMIT ISSUANCE
who contracts forsuch project with uconvactons)licensed prosoicto the Contractor's ALTER EA)
License I.aw. ( FEE SUMMARY
❑ 1 um exempt ander Sec. ,D&PC for Nie neuron BACK FLOW PItO'D?CI'.DEVICE TSIDE,FEES
SANITARY YN
Owner Date .CEIPf p
WORKMAN COMPI:NSATI'n LARATION DRAINS.FLOOR,ROOF,AREA,COND. SCHOOL TA Y N
c❑clhembyafOrmNfinummeacesificalof nun oulf-iasure.or Lab C.)which
RECEIPT'N
Workers Com Fl%TURFS-PER TRAP
peoution htumnce ore cenifi copyN nf(Sec.38W,lab C.)which PAR Y N
ple rsull<mployce's undo this pertnif GAS-EA.SYSTEM-1 INC.4 OUTLETS SION
Policy# IVISION IFFC
mpany GAS-G.SYSTENFOVER 4(EA) 1 +C
❑ CenifieJ copy is hereby fu nl.
C1 Certified copy is Filed the city impaeion divisio GREASF/INDUSTRL WASTE INTERCEPTOR GRAD
Is—
C, ICATS OP RXEMfT10N FROM RKERS' GREASETRAP SOI
COMPENSATION I NSURANCE
or s.)
sxetion need not he completed into pecoodsfaro huodreddollare 151(10) SEWER-SANITARY,-STORM EA.200FIL EVER
le �
lecoify Nniin Neper(orma ecof Neworkfor wnich Ni permit is issued,l shut] WATER HFAIER WIVENT/F.LECfR
not employ any person n any monad ao ea to become s bRct to the Wmkeos PAID
z Cm penestion laws or Califomia. Dote WATER SYSTEMMEATING Date Rea M
API icam
z NO' CF.TO APPLIC ''If,ah ing this Ccnific ofE prion,you should NEW RESIDENTIAL PLMIL SQ.FT. T AL.
(" rn bcco m subjeO to the Work s urian provisi o(the labor Code,you must
(ante lh comply w t onhis pe shall be deemed mucked. BUILDING FEE
a [� TRUCIRON LE [NO AGENCY SEISMIC FEE
z 1 h by affirm t ere is a constru on lending agency for the performance of O ELECTRIC FEEU O thnwmk awhichthis mitisissucd cc.3097,CIv.CJ
Lender's me PLUMBING FEE
O Leader'nA dress QTY. MECHANICAL PERMIT FEB '
U 1 ani Nat I have mad I application and state that the above information it
fi, torten.lag emcomplywit Il city nal county ordinances and sum laws relating to PERMIT ISSUANCE MECHANICAL FEE
vy builm.,eins etion,such byaulhodu ropmunutivesaffid'eit tocntcrupun Ne CONSTRUCTION TAX
U Z shave-natio ed propos or inspection purposes. ALTER OR ADD TO MECH.
(We)v <to sav indemnify and keep harmless Ne City of Cupertino against a
liabilitics,judg sat s, is andexpenxs which may in anyway accrue against said City AIR HANDLING UNIT(TO 10.1100 CFM)
loco/nseq�u�eLn,Zcpe�.t greene1in�g of lhi.iiennot, AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Apdicpn000gCCao/n1F'%cfpBLr < Dee ••l EXHAUSTHOODDY[DUCI)
PAID
HAZARDOUS MA'T'ERIALS DISCLOSURE.
HEATING UNIT(TO IW,000 BTU) Date Receipt#
Will the upPlicwt or future building occupant store or Handle haaardeus motorial
ondefned by the Cupertino MunieFul Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,"BTU) p 'TOTAL:
Cale.Section 25532(e)^ VENTILATION FAN(SINGLE REBID) ^�
11 Yu El No pw im
BOILER-COMPQHP OR 100,000 BTU) `� ISSUANCE DATE
Will eheam
pplicantorfure building occupant uxequipmemordcviccs whichemit b
hoennbus air contanlinane as defined by he Bay Area Air Quality Management BOILER-COMP(OVER 1001010 BTU)
Distdct] I:] 1995
❑Yca No NEW RESIDENTIAL MECII. SQ.FT. r�`FCH
1 have read the incurious materials requirements under Chapter 6.95 of the /hv
Culifombt Ilenilh&Safely Cale,SucOonx 25505,25533 and 25534. 1 underetund Incl VV
if Ne building does not currently have a]corm,that it is my responsibility 10 miuy the
cupool of the requirements equireents which mull Ina issuance
mel prior to of a Certificate of
Occupancy.
Owner or umhoriud ogee DatcT L: ISSUED BY:
OFFICE