28281CITY OF CUPERTINO nmL+arm.-a.t.'s 531.11. I rrnma no.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIXG-M IDENTIFICATION.
2 O 2 8
l,�.d_1.a..,:'BUILDING PROJECT IDENTIFICATION.. � �� G o G o 1
TOTAL: ISSUED
OFFICE
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CONTACT: PHONE: �- 'a.-'-"'•BUILDINO
QTY. "% ` ELECTRIC PER69T-w.�'' : :{ -i' -FEE::,'. -
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-PERMITINFOWe iL•'X%
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL
Ihereby offices that l an licensed underpmvisionsofaapter9(commencingwith
Section 7") o'f�n! Jo(the Business and Profession,C and my license is.. PANELS
full to. eclimypc`1� Lic.a'JC�_ UPT02MAMPS
Licenu Clan VVV r�
Date f��eJ�N �CContractor 201 - 1000 AMPS
JOB DESCRIPTION
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O ARHITECTS DECLARATION OVER IOW AMPS
1 mdemand my plans shall be used as public records.
SIGNS ELECTRICAL
SQ. FT. FLOOR AREA
FT.
Licensed Professional
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OWNER -BUILDER DECLARATION SPECIALCIRCUITIMISC.
1 hereby affirm that I an exempt from the Contractor's License Law for the
following reasan.(Section 703 L5, Blind. and Professions Code: MY city a rounry TEMP. METER OR POLE WST.
which .quirts a permit b co mutt, alter, impure, demolish, or repair my structure
poen. its issoaoce..lu residues theapplicant formeh peruvm fil... igned roomer, POWER DEVICES
that he is eicensed pummnt to rhe provisions of the Contractors License law (Chapter
9(commesring with Section]000) of Division 3 ofthe Business and POfasion, Code) SWIMMING POOL ELECTRIC
or then he iteaernpt therefrom moil Ne basis far the all,ad.mmpdon. Any vi.lationof OUTLETS - SWITCHES - FlXTURFS
Section 101 1,1 by any applicant for a permit Subjects Ne applicant m a civil penalty y of
mart than five hundred dollen (g5W). NEW RESB)ENTIAL ELECTR _SQ. FT.
❑ I, thanaoftuproperty,orm$500). Yenwimwageautheirs.lecompmadon,
will do rework. ends:
VALUATION
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ORIFS
TYPE CONSTRUCf10:
noContractors
and Pm(essions Cade: The Contracmra Littrtve Taw don ..,ply to N owner Of
.,ply. to an
properrywhobuilcis.rimproves thereon, anlwholoes such workhimreHorthrough his
employers, pmvided Nat suc h impmvcmcnu are vat in tended or offered for W e. If.
OCC. GROUP
RES.—UNITS
however. the buildingor improvement is sold within one year.fc.mpleloo, mecism, TOTAL:
builder will have me burdm.f proving Na redid tall builder improve for purpose of
We.).A,•,LUMBUJG PERMIT' �',, *"-; '� rti?F i r
❑ Lm.wn<ro(the pr.pertY.amesduaiveeymnvaaingwimlicenud ront3ecwmo e..e, s„ 7, s• ,e
.muust the project (Sec. 7(om. Business and Professions Cade:) The Contracmra v'Mpp ISSUANCE _
Limo Lawdoean.taMly a mownerof pmptm wlwbuieds.rimprovea thawn, aM
FLOOD ZONE
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who contracts forsuch projects with neon==&n Licemedpunuattothe Contracmes ALTER-DRAW&VENT-WATER (EA)
License Law.
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❑ 1 sun exempt under Sec. , B & P C for Nis reasonBACK FLOW PROTECT'. DEVICE
OUTSIDE FEES
S ITARY Y N
Owner Date
RECEIPT.
DRAWS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
S LTAX y
..
; by off thml haveattnificaeofco nst.lett.im,..a.ttnifscateof FI%TURES - PPR TRAP
Waker%Camperrom Insuance ora cej�ified coPY then:of(Sec,JSW.Lab CJwhicry
covers Is. Y e'a a,f N' a fit"/.?��'f GAS-EA.SYSTEM-1INCA
Policy• fs/ 1
RET•
P FEE Y N
RECETPfx
BUILDING DIVISION FEES
r"•"" GAS- YSTEM-OV (
PLANECK FEE
Q�Cpltrsd copy i5 hereby furnished.
GRADING FEE
enified copy is Bled with the city inspection division. REAS N U W OR
CERTIFICATE OF EXEMPTION FROM WORKERS' fiFAS
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(Otis section need not becompleted ifthe permit is formehundied dollars(SIW) S WER-S IT RY- RM .2orin
or leu.)
I certify that in the pertmmance of the week for which this permit is issued, l shall W TPR HEATER W/VENT/ELEM
not employ any person in any number so as to become subject to the Worker
PAID
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Cost,matianlawaof C.lifomia. Date W SYST wnwATING
Applicant
Date Receipt.
NOTICE TO APPLICANT: If, after basking this Cerdfaae of Esernption. you should NE RFSIOfiNTIAL PCMB. SQ. FT.
TOTAL:
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become subject tome Workers Compenaarionpmvuiau Ofine labor Cak. you must
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forthwith comply with such provisiarn or this smut seed) be deemed evoked.
BURDEN; FEE
SEISMIC FEE'
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CONSTRUCTION LENDING AGENCY
V OTOTAL:
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romee of
1 hereby affirm tha mere is a construction lending agency for to piefet
Ne suer for which this permit is issued (Sao. 3097, Civ. C.)
Lenders Name ••' - r,v s-au.e-•;r•'a-.;x-•«r...-. ,hw�c f. Y.
ELECTRIC FEE
PLUMBING FEE
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Lenders Address QTY. *: `. `t•.•, MECHANICAL PERMIT +.� u FEE �
I certify met I have mad this application and sate that Ne above information is i' "" "-"" w.+r! n n •e.rvnw-,m-$?aJ;Urt�;l
erect.lager to comely with all city and county ordided. and sou laws elating. PERMIT ISSUANCE
buit,ingcomtruction. and hereby authmiu mPreuntasives0(this city m emerupomhe
above-mentioned property for iin swan purposes. ALTER OR ADD TO MECH.
MECHANICAL FEE
CONSTRUCTION TAX
Me) agree to .vase, indemnify and kap harness the City of Cupertino against
Iiabilitin,judgmenu,cosu undeapenes which may in any waysecmeagainst said City AIR HANDLING UNIT (TO ffl," CFM)
inconsequence of the granun6 of this permit.
AIR HANDLING "IT OVER 10.004) CFM)
PAID
Sigramm of ApplicantlContracmr Dote EXHAUST NEED(WIDUGp
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU)
Dau Receipts
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Will meapplicant ar n resonant hanmaterial
Xture .1Card, Chapter 9.12. and the Health and Safety HEATING UNIT (OVER IW,OW BTU)
m defined by he C,irtino M ...
Cad, Section 25532(.)? VENTILATION PAN (SINGLE RESID)
❑ Yes
'
Willmeapplicar ser fuw b 'bui goecupamux equipmenmrdevicowhichemit BOILER- COMP(3HP OR 100,000 BTU)
ISSUANCE DATE
harurduus air conumi-tom toed by the Bay Ma Air Qualiry Marwgemem BOILER-COMP(OVER 100,000BTU1
Disme,?
❑ Yes o NEW RESIDENTIAL MECIi. SQ. FT.
I have mad the harmless materials requiremrnu under Chapter 6.95 Of the
Califomw Health & Safety Code. Sections 25505, 25533 and 25536, 1 understand the
if the building does nm currently have a inert, that it is my responsibility a notify the
occupadlof toe regmWmenq,4li b rot 4 r,"r to issuance of a Certificate of
-AUG 1 LD
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TOTAL: ISSUED
OFFICE