28164 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDI C-ELECFRICAI, PERMITNO. 28164^ 1^4
BUILDING DIVISION APPLICATION/PERMIT PING FROB NG CIFIDEANIFIC L VY Vh
BUILDING PR(AF:CI'IDENTIF'ICA'FIlkN
BUILDING ADDRESS: SANITARY NO. APPLICAFTIIIONSSUgBMITTALDATE
`FWDnjwZPO UNIT# LOT CAA s
LT LIC NO: V
M99 5%ry NIC ^ /� CONTROL g
R: ICN .
CONTACT: P :L/s N1 V BUILDING PERMIT INFO
I..�� �NE: QTY. ELECTRIC PERMIT FEE
4�J1111 ILiC�/IY rl I�I�iL(J PERMIT ISSUANCE. '— BLDG ELE PLUMB ME
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDEM'IAL FOB DESCRIPTION
Matz I hereby affirm that l am licensed underprovisions of Clvpter9(commencing with
�00 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
eg full to.and effect.
fU'2W Licenae Class Lic.g UPI'0200AMPS
a1 Dam Combine 201-IOW AMPS
y SQ.FT.FLOOR AREA NSQ.FT.
2F-y ARhall he.CTS DECLARATION OVER ItXq AMPS
0002 5 O 1 understood my plans shall be used as public records. ,..a
C=Y0.i L';Q
SIGNS ELECTRICAL
e S
Licensed Professional �
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
x0.x0{i0.10 1 hereby affi I A�sann exempt from the Conmacmr's License lutes for the
W 3 a y¢ following reams(Se on]0375 Business anJ Professions Code:Any city or county TEMP.METER OR POLE.INST.
S 0 J which requires n pe it w connruy.alter,improve.Demolish.nr rapes any swaure
Pratt its issuance Im requiresmhe licant fanuch permit mfileesigncd stetemein POWER DEVICES
3gj C, that he is licemed ursuam oche prmisVtsmonf the Cnmmcmrs Littnx Lew(Chapter SWIMMING POOL ELECTRIC VALUATION
0.g0�' 9(commencing th Section]IXIO)of Di fth Bminess and Professions Gaiter) ' I
iW_w or Nethe isaxe pnhcrefrom anJ the bvia for the' cmption.Any violation ofOUTL1?TS-SWITCHES-FIXTURES
FZQ Section]OI I. by any applicant fora permit subjects aPPliummacivil penalty of
nm month five hundred Nsllva(ES ). 111111
❑ 1NEW RPSIDENTIALELECTR _SQ.FT. STORS TYPECONSINUMION
vtn ,na neroHM1epropeny,orm wi ge theirsolecompensatioa
y3_ wall ds
o ewod,end the ateucm t dedor feredfonele(Sec.]Bia,Bmsiareof
enJ P fmsionr Cale:The Con i Littnu dnea not apply to w owner of '
proper wbobuildsarimprove tie dwho s uch workhimselt onhrough his OCC.GROUP RES.UNITS
ownem a ms,pmvidedrha provementiare not intendedorofrered forsale.If,
however. ehuildingorim ant isaoldw hinmmymofcompinlon,theowner- t.
builderwill aveth me sing that�ei dmotbmildaimprovcforpammeof
auto) rosin ' QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ T,asowner the maim exclusively contracting with licensed conaacorsto
construct the proje Sef. ,Business rand Professions Codc:)The Contractors
Licmpu Lawdeesnoo Iymanownerofyopenywhohuildsorimprovesthereon,and PERMIT ISSUANCE
whoconmunficrsnch pro I xiNacon toR)liccnud pmanchimsheCt,rapamr's ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
License Law.
❑ Ism exempt under Sec. ,B&P C for this¢ams BACK FLOW PROTECT.DEVICE OUTSIDE.
FEES
SANITARY YN
Owner Dau DRAINS-FLOOR,ROOF,A GOND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ibertby affw that lhave amnifcate of consem to eel(-insure,art acertificate of FIXITIRES-PERT RECEIPTp
Workers'Compensation Insurance,or acenified copy iherenf(Sec.3800,Lab C.)which PARK FEE Y N
all employee's code(this .it. GAS-FA. TEM-I IN040UTLF.TS RECEIPfg
PolicyrsIs BUILDING DIVISION FERS
and Cef -EA.SYSTEM-OVER4HVU PLANCHECK FEE
[I Certified copy is herebyfamished.the city
❑ Certified copy is fled with the city inspection division. GRFASE/INDUSTRL WASTE INTERCEPTOR GRADING FIX
I
CERTIFICATE:OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This action need not be completed iUhe permit is lorotm hundreddollurs(EI SEWER-SANRARY-ETDR WI•T. ENERGY FEE �^
or less.)
I terrify that in the performance of the work for which thiepewit isissued.l shut WATER HEATER WN R
not employ any person in any manner so as to become mbjen w the Workeas' PAID
Compensation Lowsnf Callfomia. Date WA SYS G 4 Date Receipt
O z Applicant
z O NOTICE TO APPLICANT,lf,afw,making this Cenifcateof Exemmold NEW TIALP SQ.PT. TOTAL:
�+ (J becomesubjec mthe Worker's Compensation provisiomof Ne Labor Cale,you must
forthwith comply wMauch Provisioor this permit shall be domed revoked. BUILDING RB
re �.
4kI Q CONSTRUCTION LENDING AGENCY ix SEISMIC FEE t�
I hereby alfmt that there is a construction lending agency for the perfortsmnce of
L) O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEG W �.
Lenders Name PLUMBING FEE
lenders Address QTY. MECHANICAL PF MIT FEE
D U I ecnify that I have read this application and nom that the above information is MECHANICAL FEE
i: 0. correct. Ingrcemcomply without cityinl county adinences it ave laws relatingte PERT ISSUANCE
buddingcnmmvatico, it herebyauthorize representatives of Nis cityo enmrupon the CONSTRUCTION TAX
L) z above-menu. y far inspection p rpones. ALTER ADD TO .CFI.
( gree to s <,indemnify and keep haamuess the City of Cupertino agwnn
Its mes,j.d . ,costs andexpenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10.000CFM)
consequence egmnti %his parank.
AIR HANDLING UNIT(OVER 10,0118 CFM)
Signewm of I icant/Cmroacor Date EXHAUST HOOD(W/DUCfI PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Data ReceiptN
Will the applicant or future building occupant sore or handle hazardous material HEATING UNIT(OVER 100,001)BTU) L:
as defined by the Catarina Municipal Cak,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)T
❑Yes 11 No VENTILATION FAN(SINGLE.RPSID)
ISSUANCE DATE
Walthc applicautcrlutumbuildingoccupam userquipmenmrdevices whichemit BOILER-COMP(3HPOR 100,00013TU) PAID AP� I D
haeadous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) Ir
Dieter)
❑Y. ❑No NEW RESIDENTIAL MECII. SQ.FT. -YYN 12 1995
1 have read the harmdous matcdab requirements made(Chapter 6.95 of the
Cif tlhiefnbmuivalJlinleg dliolmc&s nSutafteutymCeno0ye,hSe«veGeonmsn2n5n5L0t5h.a2t 5it5i3s 3may dre2s5p5oMnsi.biIlmitnydteorsntoatnidfy Nthaet
CITY
Vf VV
Oectioat of the requirements which must be met prior o issuance of a Ccmificam of
Occupancy.
Oww""nothodaedagmm Data
TO' ISSUED BY:
OFFICE