28088 APPLICANT TO FILL IN INFORMATION S IUSE BALL POINT PEN ONLY
CITY OF CUPERTINORUII.DING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICAr I PLWte1NG-MECIIANICAL. 28088
NUILDING 1'ROJEC'1IDEN'UFICATION
BUILDIINGG/ADDDRREESSSy_�T/—' ,� ♦ SANITARY NO. APPLICATION SUBMITTAL GAIT.
LINIT# J♦1
OWNE�A � PHONE: CONTRACTORSi�S NAE
' NIC J
CONTHOLp/CrV
RCHITECl/ GINF,ER: LIC NO: ADDRESS: ❑ I /
CoAQ ♦� BUILDING PERMIT INF
�Fw�V Q'PY. GLIiCTRIC PIiRMI9' IFI:
2LDG ELECT PLUMB MF.CII
PERMIT'ISSUANCE
�y li% - El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
py.Z Iherebyaffitm@at l am licensed underpmvisionsofChapler9(commencing with TOR DIiS
WOO[ Section 7000n fDivision 3ofdw Buslnasnnd professions Code,and my It...is in PANELS
t��U full force and effect. UP T0200AMP5
FZ License Class Lic.p A
r <c. Date Cmanna.r 201-11110 AMPS
ZOyz ARCHITECTS DECLARATION OVER 1000 AMPS SQ,M.FLOOR AREA $/Q.FT.
OZ-0 lundettnnd my plana shall be used as public recnnIs. �/#
OmIJPk-m SIGNS ELECTRICAL -
'� LiwnseA Pral'essinnol
OWNER"BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
CLLU1 hereby from that I am exempt from the Contractors License Law for the
aOQ following as.,(Section 9031.5,Business and Poofessi.ns CWe:Any city.,roomy 'I EMP.MET ER OR POLE 1NSl'.
which requires a permit to conawn,alter,improve,demolish,or repair any structure
�r ,,its issuance.ulsorc vires the luso forsucM1 u.lBe asimeJ ntummrm POWER DEVICES
prior y pp pcnni b
O LL that he is licensed pursuant to the Provisions of the Computers License Law(Chapter
°i pyo 9fc.mmencing with Secrmn lOW)ofDivision 3 mfdw Business and Professions Code) SWIMMING POOL ELECTRIC ^ VALUATION
L:Ky Sectioheiseabyany mfromnt for
a bvonnitsbjs far ets the applicant
to civiny l
of OUTLET'S-SWITCHES-FlXTURES (.�Q� Laf,.�I �^
Z0' net.l031.5 by anfive y cant fora pemtit subjects the upplicvm eacivil penelry of
not moretBenr.flhedodrty,armycm). NEW RESIDENTIAL EL.F.C1R S Fit.
y� m ❑ LasOwnmofdthe sperry,ormycmployed oroferegcsaslhe(sure c0mpBusiness Q STORIES TYI'Ii CON$TRUCHON
will dothewors and the he CoreisnotinLndeJo Lawd esnotl apply to an owner
of
and Professions ldsor The Cont aves eremi License Law such
not apply a an owner of
morerOwyses,pdsvidedi exact improvements
doessuch workhuroffi unhrough his OCC.GROUP RES.UNITS
wnemployees,provided thatsuch ant is sold
wit arenot intendedoroffered tarsale.IL
however,the illhabuilding teburmpmvcmentissat he
none ot bull rofI noveifn.rthwwe of 'TOTAL:
builder will have the burden of proving that M1e did not buil t ve for puryou a(
sole.), ro
❑ Lusosanerofthepropmy,emexclusivelycomr ting wiN licenser mmctomm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the Protect(Sea IOM,Business and dessima Code:)The racoon
Licenselaw doeanol apply loan ownerof pro ywhobaiiJsminap,ve,nar nand PERMIT'ISSUANCE
whoco mace forsuch Projects with atom or(s)licensed pursuant the Contra o
License Luw. � ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt undo Sec. .B&P C for this rens0 BACK FLOW PROTEGE DEVICE SANITARY OUTSIDE DD—ES N
Owner Data DRAINS-FLOOR,ROOK,AREA.GOND. RECEIPT#
WORKMAN COM'ENSATIONDECLARATION SCHOOLTAX Y N
❑ Ihcreby affpm tlutlhaveac 'Bate nfconsemto ulf-insure,ore nificam of RECEIPT'#
Wnrkcre'CampcnrmiOn lnaurvnce or.ceniOCJ copy @ertof(Sec.38W,La C) IIXTURES-PLR PARK FEE Y N
covers I emplo ee'aunder this Penni -F - YS - 41NC. UTLIN's RECEIPT#
Policy# BUILDING DIVISION Fit S
:pCeniuny G - t .S TF.M-OVER4( ) PLANCHECK FEE
��y7„ Fled copy is hereby famished. Ln
Cenifed copy is riled wilb the city it vPectiu d\s / GREA INDUSTRLWASTI:IN ERCEPI'OR GRADING FEE
CERTIFICATE OF EXEM HON PRO WO KERS' / G ' SETRAP SOILS[ZEE
COMPENSATIO INSURA CE
(nissemi,mocednolb0wmpleedlf epemtitis hundred doll 0100) SEWER-SANITARY TORM . OOFT. ENERGY FEE SS SMO
.rless) 7
I certify that in the performance of the oak for which this permit jissued,I shall WAIF EATER
of snuff,any person to any manner s0 to become subjcc the Worke � PAID gin I es
7-. CmrZ,mtion Lswaof CellfimZ Date SY 'NT/I'RPA G Date i tX I
Applicant
Z�Z�-1 NOTICE.TO APPLICANT If,ager making this&iltficll.Of F, mption.you shouldRP F IAL .MB. SQ.FT. TOTAL:
F' p] breams suhjen thm
to e Wnrker4 C. pvnsntion pravisiom Of lheh nCoda your...,
FFFa'" ; forthwith comply with such provisions or this permit shall he deem J revoked. BUILDING PER
Wz CONSTRUCTION LENDING AGENCY SEISMIC FEE
rrR, 1 hereby affirm that is a construction lending ngency for Ih to re of
C..) O the work for which this permit is issued(Sec.3097,Civ.C.) 'TOTAL: E1.ECTR IC FE Ii
Lender's Name PLUMBING F1iE
O [V-+ Leneers Address Q'fY. MECIIANICAL.PERMIT FEE
1 certify the 1 have read this application and sem that an above\, T7el
uon is
,o)
correct.Iagreeecnmply sashall yautyand wmmynNinunwsand site Iore P MIT ISSUANCE MECHANICALFAR
building convrveti0n,and heresy amhariu mpreunutivcs ofthis citym .n to CONSTRUCTIONTAX
Znbov.nuad red pmpeny for inspectina purposes. ALTER OR ADD TO MICH.(We)agree to save.indemnify and keep harmless the City of Cupgninst
Iiabilitics,judgmets,ensu and rxpenses which may in anyway accruers id City AIR HANDLING UNII'Q'010,000 CFM)
to rnnver ounce of the gmndng of this permit
AIR HANDLING UNIT(OVER Iq(XIB CPM) `' /`
Signal..of ApplicanJCommcmr Do,.- 13XI1
AUST 11001)(W/UUCI) PAID �bN I0
HAZARDOUS MATERIALS DISCLOSURE HEALING UNIT TO 100,000 BTU) lura Receipt#
Will the applicant nr furore builAin6.ccupamsrore of handle htnarJ.us mtrrivl TU)
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety IIEA'ryNG UNIT(OVI3R 100,000B TOTAL:
Cade,Section 25532(01
Year �s�a�,.-, n�� VENTILATION PAN(SINGLE RESID)
❑ \r
BOILER.COMP IMP OR 100.000 BTU) ISSUANCE DATE
Will the aPplirunlnrfa as defined by then mw equipment unlit Management
it P A 1 U
hazerict? air conl:uttinunu m defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District^ o
❑Y. NEW RESIDENTIAL MECH. SQ.PI'.
I have read t as requirements under Chapter 6.Athm
MAY 191995
Culil a Ile:dl my Code,m lions 25505,2.5533 and 25534. 1 underiflhe buibut mly e a tenant.that it is my responsibilitye L!1-
cupan -remems whi<v user ht met p' to" nee of a C V LUrEHiINO
Oc` D TOTAL: ISSUEDIi Y: O�v
OFFICE
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