28131 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 ILDING-ELF. '1'RICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBNG-MECHANICAL
WICA 28131
ItU11.DINC IBf3JECT If1EN'1'IFICA'1'ION v
BUILDING ADDRESS: loot Phl+� �.Y SANITARY NO. APPLICATIONSUBMITI'ALUATE
I� ✓'4 n UNIT# s LOTR CC)
WNERSN . E: PHONE: CO TR OR' v� LIC NO:
Cpl C CON'T'ROL#
ARCA F 71NGINITH: UC NO: ADDS: 1:1CO n?T C PHONE:
QTY, GLIiCTRIC PERMIT PER BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:SSUANCF. 00 101 ® El El
LICENSED CONTRACTOR'S DECLARATION RESIDENTIAL tAI JOB UE.SCRIPfIp�'
Qmz hereby affirm that l am licensed underprovisiomnfCbupter9(commencing with C /•I —g�
POO Section 7000)of Di ision 3oflhe Business and Profession Code,and my license u in
loallt-W Cand effect.
License
L� Date Class Convactor201T0100(1 AMPS
FyZARCHITECTS DECLARATION — SQ.FT.I'LOOR AREA $/SQ.FT.
z O o,_ I understand my plana shall be used as public immds. OVER 1000 AMPS
OZ^Q
F y'[; SIGNS I?hECI'RICAL
QY Licensed Professional
L4K 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. / 0
xdOa V I hereby affirm that I sum exempt from the Convectors License law for the
W atrO`Fv' following brawn.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a Permit to construct,alcor,improve.demolish,or repair any structure
}� prior to its issuance,also requires the applicant for such Permit file a dgne0 statement POWER DEVICES
rm
HO that he is licensed pursuant tothe provision primConductor's License Law(Chapter
0. oLL 9(Commencing with Section 7000)of Division 3 ofthe Business and Profession Code) SWIMMING POOL ELECTRIC VALUATION
wpm or Not he is exempt hercfmm and the basis for the alleged exemption.Any violation of OV
Za Section 7031.5 by any applicant for a pmunitxubjects the applicant to a civil penalty of OUTLETS-SWITCHS-FIXTURES
nm
f� /!' ��
Q t more than rive hundred dollars($500). D
C m0
❑ LesownerCfthepropery,ormyemployuswiN wagaes Nei...lecompenatim, NEWRISIDIN'GALBLF.CIR _SQ.FT. STCR ' '1'YPECONSTRUCTION
y,q_ will drahe work,and the structure is not intended oroffcred forsals(Sm.7044,Business
and Pmfasions Cods:The Contractor.License Law does not apply to an owner of
progeny who builds or improves thereon,and who does such work himselfor drought his
own employees,provided that such improvements arc not intended oroffeed for sale.If, X N OCC.GROUP )TIES,UNITS
however,the buildingor improvement is sold within one yearofcompinisn,the owner
Ix
builder will have the burden of proving that he did not build or improve for purpose of T AL. ��� �'
sale.).
❑ I,aanwneroftheprnpeny,um exdusivelycondacting withlicensed cnnvactofstn QST' PLUMBING PERMIT PEE FLOODZONE APN
construct the Pa t(Sm.7(k4,Business and Professions CaIC:)True Contractor's
License Lawdoea not apply toennwncrofpropenywho buildsorimproves barman,ward PERMIT ISSUANCE
whoammumv fm such projects with acomencmr(s)licensed pursusnno the Contractor's
., License Lew. ALTER-DRAIN&VENT-WATER(RA) IEE SUMMARY
❑ I am exempt under Sec. ,p&P C for this reason O I S-11 : .F..
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOLTAX Y N
I hereby affirm that l have.emilieateofconsentto self-iream,oracenifcatc of FIXTI1RIi5-PI?R TRAP RECEIPT
wmlcrs'Compans.tion Insurance on eerifilai copy Thereof(Sm,3800.lab C.)which PARK FEE Y N
ovll1Kdtm IIPT N
CPoliecyah� VJ00,5YD CAS-[A.SYSTEM-I INC.40UTLE1S
# BUILDING DIVISION TEES
Company GAS-EA.SYSTEM-OVER 4(PAT PLANCHECK FEE
Car ifiml copy is hereby furnished.
Certified copy is filed with the city inspection division. GRFASIWNDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION MOM WORKERS' OR EASE TRAP SOILS FEE
COMPENSATION INSURANCE
('ITissmtian need not be completed lithe permit is torose hundred d.11.($U10) SEWER-SANITARY-STORM IA.200FU ENERGY FEE
orless.)
I certify that in the performance bible work for which this permit is issued,l xhall WATER I IEATIT W/VGNT)ELECI'R
not employ any person in any manner so as to become subject to the Workers PAID
Z Compensation Lawxof Culifamia. Data WATER SYSTENVTREATING Data Receipt Is
Applicant
ZOD NOTICE TO APPLICANT:If,me,making this Certificme of Exemption,you should NEW RESIDENTIAL PLMH. SQ.FT. TOTAL:
V) become subject to the Workers Compensation provision of the lalnr Cale.you mum
� ; forthwith comply with such provision or this Permit shall bs deemed revoked. BUILDING FEE 19goo
0. Q CONSTRUCTION LENDING AGENCY SEISMICFEE s go
Uz I Thant affirm that is a construction lending agency for the performance of [ TAL: ELECTRIC IEE J �D
O Outwork forwhich this permit is issnd(See.3ND.Civ.CJ
PIznder's Name PLUMBING FEF.
Leader,Address QTY. MF.CHANI LPE�' FEE
V 1 certify that I have read this application and state that the.Fame information is
embed.lilies,tocamply with all city andeountyonlinsimmand state laws relating to PERMI'PISSUANCE MECHANICAL ME
L'I building construction,and hereby amhariu representatives ofthis city to enter upon the CONSTRUCTION TAX
V Z move mentioned properly for inspection purposes. ALTERORAUDTOMECI E.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
linhilities,judgments,cenIno
expenses which cony in any way uccme.gainst said City AIR HANDLING UNIT(TO IO,IKKI CIM)
in e ofthc in this 't.
AIR HANDLING UNIT(OVER I0,0I0 CFM)
ZIA
S' cnf pp ma/Contructor m EXHAUST I IOOD(WIDUCq
PAID Slate gh R#
HAZARDOUS MATERIALS DISCLOSURE
ELATING UNIT(TU IW,UW BTU) Dam Receipt#
Will the applicant or future building occupant store ohazardous material
es AefincJ by the Cupertino Municipal Cade,Chapter 9.12,,end and the Health and Safey HEATING UNIT(OVER 100,000 ETU) pp tT�TO'T'AL:
Code,SecOnn 255.12v)?C3 Yes / VEN3'ILATAION FAN REBID)
"N No BOILER-COMP(311P OR 1 W,01K1 BTU) ISSUANCE DATE
Will the applicuntmfmurt
building we an devices whichemit III 5 1995
hamm rdnus air contaminants definedemrn
by the Bay Area Air Quality Manugt BOILER-COMP(OVER 101),"BTU) MAY 2
0 District?
13 Yea XNn NEW RESIDENTIAL MFCH. SQ,FT.
I have reed tbe,haurdan materials requirements under Chapter 6.95 of the
Cil I Y Vf V I IIVV
iftheail Ingcaldldo&Safety amly Smhon 25505,25533 and 25534. 1 undmsmnd that /I
if the building does not,rtcn0y have a tenant,that it is my responsibility to notify the �•/7�
occupant of the res neat which be prior noes of u CenlBcam of
Occupancy.
owner nr .t g t Dam TOTAL: ISSUED BY: Joe— /�-NTJt t•GG.+
OFFICE