28375 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, - PERMIT NO.
APPLICATION/PERMIT PLUMPING-MECHANICAL. 2 O
BUILDING DIVISION 'IiUILDINf.PR(1JEC'1'IUEN'I'IFIC,AI'IUN L o 3 7 r
3 'V'1/
BUILDING ADDRESS: SANITARY NO. AP/PLIC/CATION SUBMITTAL DATE
fl UNIT# LOT is
OW RS NAME: PHONE: CON RTO 'S F.: LIC NO: - ! ll
/d N/C CONTROL#AR IIII'EC'1'/ENGINEER: LIC NO: A `0&d- rF_L �J� •/ Rte[ C ❑
CONTACT: PHONE: - - L •/
QTV{ ' ELP.CTRIC.PERMIT FEE 'BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES�RESIDENTIAL El V El r
q CGZ I hcrebyaffirm thm lam licensed under provismnsof0after9(commencing with JOB DESCRIPTION
P400 Sectio.9000)of Division 3of,he Businessand Profession Code,unit my license is in PANELS
a�� Poll fo cc and nl[ t.
4 License as
L # a�147Z UP T0200AMP5
W
my Dam — Conwcmr 201-1000 AMPS
ZOyZ ARCHITECTS DECLA ATION OVER 1000 AMPS SQ.FT.FLOOR AREA $ISQ.FT.
I understanding plans shall be used as public circuits.
r y F W SIGNS ELECTRICAL
Q- J Licensed Professional
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUI'f/MISC.
X,yu I hereby affirm that I am exempt from the Contractors License Law for[lie
W✓WrFi. fullowing reason.(Section 703 1.5,Business and Professions Code:Any city or county I'EMP.ME'PER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its Issuance,al se re the applicant for such unit m life a signed.a,emem POWER DEVICES
w�II quires pp pe
fyCMO the he isnlicensed rursmion700 )d to the ofE iisms the Contractors License Law(Chapter
W o�' 9(enmmencing with Section 9000)of Divislon3of the Business and Professions Code? SWIMMING POOL ELECTRIC VALUATION
or that he isexempnherefromand0e basis for thoalleged exemption.Anyviolmion of OUTLETS-SWITCHES-FIXTURES
QSection9U31.5 by any applicant for a permit subjects the applicant to u civil penalty of
not more Dan by
famished coitus($500).
tz] � ❑ 1,asownerofthopropeny,ormyemployeaswithwMesnstheirsolecompe... NEW RESIDENTIAL ELECTR unit, —SQ.IT. STORIES TYPECONSTRUCHON
y wit Ido the work,and[be snatcher not intended orieforat for sale(Sec. Business
and Professions Code:The Clamberer's License Law does not apply to an owner of
,recent, he builds or impnsesdarnm.and who doessuch work bimeelfludin gh his
own employeev.pmvidedthat such improvements oro norintended orofferedftersale.If. I OCC.GROUP RES.UNITS
however.the building or improvement is sold within one ycmof completion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale) ° i--
propery yarn gwn QTY. PLUMBING PERMIT > `FEP - FLOOD ZONE APN
❑ Las thne,.jcc, L,amexinsvel haemo Coade:)The nlmdm.to .'q ti
rmnswcL the project(Seo.loan
Business and Professions CodmJ The Connaaoh
Licensetrawdforsucapplytoascub ac mmaborny wausedpirstaf omeCereogarA PERMIT ISSUANCE
whence Lactsforsuch projects wi,ha comracmr(v)IieenseA pnrsunmtolhoCon.acmds ALTER EA '
License Law. ( ) � � - - , FEE SUMMARY
❑
lam exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE PE S
SANITARY Y N
Owner Date RECEIPT#
• DRAINS-FLOOR.ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby affintthmlhave
ance cr ificateuf coneminselGinsurc,or Lab C.)e which FIXTURES-PERTRAP RECEIPT#
Workere'Compensedon lnsumnceorvcertified copy thereof(Sec.3go0,Lab CJ which PARK FEE YN
cnversallearipGAS-EA.SYS M-1 INC.40 TS RECEIPT#
Policy# to GAR.-
BUILDING DIVISION FEES
pa'tY r u'T — GA -E -OVER4 PLANCIIECK FEE
C.dfiod very Is hereby furnished.
Canifiel copy is filed with ihccity Inspection division. GRE DU ,INTERCEPTOR GRADING FRE
CERTIFICATE OF EXEMPTION FROM WORKERS' TRA SOILS FEE
COMPENSATION INSURANCE
(This sermon need not betemple,edlithe permit is furore hundred dollars( I SE 4R-JANJTARY-STORM P.A.200Ff. ENERGY FEE
ort f
1 shall
(certify that ina.p in anyficann,w, a for whichthisiubject to issued,lkers' WATER HEATER W/VF.MI'/ELECIR
urn employ any peso. li any manner so as m hewma subject to the Workers' pplp
Compensation Laws of California. Dune V WATER SYSTEM/TREATINGZ Applicant Dole Receipt is
'z Z O NOTICETO APPLICANT:If,otter making this Certificate of Exemption, should NEW RESIDENT IAL PLATE. S FT.
^ p ten,you s ou Q TOTAL:
— become tithcomct ply the Worker's Compensation recent
ons all beoLiborevoked, must
Ij forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I batch,affinnflatthere is a construction lending agency far the performance of 'TOTAL: ELECTRIC PEE
O the work for whichthis piano,is issued(Sec.3099,Civ.C.)
O FLenders Name
Lenders Address QTY. - MECHANICAL PERMIT 'FEE PLUMBING PEE
U I certify that I have mad this application and nam thin the shove information is
acouncil.lagreo no comply with elle,,and anon,nNinunces and.ea lnwsrelmingm PERMIT ISSUANCE MECHANICALFEE
building wnstructiea,and heraby authorce,represametives of this city meaner upon the
above-mentioned property for inspection purposes. ALTER'ORADDTOMECH. CONSTRUCTION TAX
F7 (We)agree in save,indemnify and keep harmless the City of C.penln0 against
Ilabilhies.judgments,costs andexpenes which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanUCon,mctor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO 100,000 BTU) Date Receipt#
Will[be applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00)BTU) TOTAL:
Cade,Section 25532(e)P
11 Yes 11 No VENTILATION PAN(SINGLE RLSID)
Will he nconaamnfuas building by the
ntay Arco Air Quality umBeemh
` BOILER-COMP(3HPORIOgI1WBTU) ` ISSUANCE DATE
. hazardous air contaminants n defined by,he Bay Area Air Quality Management
Din.ictP ❑Yes El No n Ci.A— R.P
BOILER-COMP(OVER 100,000 BTU) p S D
NEW RESIDENTIAL MECH.—SQ.UP
1 have read the hazacdons nationals reyuiremems under Chapter 6.95 of the
JUL� f�f 19
Cnlifornin IIenIW&Safcty Cale,Sections 25505.25533 and 255]4. undernard that a
if oho building does not curtently hove a tenant,,hot it is my rcsponsibili,y,o notify rhe
occupant of the rcqulrem sob, h muo be mer prior m lesuperi of a Cenificam oP
CII Y Ur k
Oecapa _/ _ n'
Owner or authorized agent Dam T ISSUED BY:
OFFICE