27028APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL PnINT PEN nNl. v
CITY OF CUPERTINO R IL°Iry--EL'ECTRI AL
APPLICATION/PERMIT PLUMBING -MECHANICAL,
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICA'TION -�
PERMIT NO. O
28
BUILDING ADDRESS. f^////'� / /)
V ( ( 1 (Wl,.-l' .NIT# LOT#
SANITARY NO,
APPLICATION SUHMITTAL DA'IB
OW ' SN ME: P ONE: ,x,.
' ARCHITECT/ENGINFER: LIC NO: `/L'J
CONTRA O AME: LIC O
ADDR �
N/C
❑
CONTROL #
CON ncr: PHONE:
QTY; ELECTRIC'PERMIT ' : FEE
BUILDING PERMIT INFO
BLDG 'ECT PLUMB MEC
"!v4:2
��`J#
N4
PERMIT ISSUANCE
❑
Z LICkLASED CONTRACT ORS DECLARATION
Iherehy afiethat adunder previsions of (commencing with
commencingwith
O Section 26W)of Div' l n3 o(the Rosiness a�nJ/�-% fe n��s C//wJJ�e, �A/m�y license 11
APPLIANCES - RESIDENTIAL
�JOB.'ID�+M.C`.RIPfI N
PANELS
Licence Classeffecl71-SLic.N `
ti Dure �(/ �(/Contractor
Z ARCHITECTS DEC ie A
A 1 understand my plans shall he usetl as publi<records.
UP T0200 AMPS
2 OWL
201 - 1 WO AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
i� C1
G/
Novwhich
Ifr n
ly t%'9111�
#
$/SQ. FT.
SIGNS ELECTRICAL
Lmeme d Professional
U OWNER -BUILDER DECLARATION
U 1 hereby affirm that 1 am exempt from the Committees License Law for the
to following reason. (Section 70315.Business and Producers Code: Any city nr county
requires a permit to construct, alter, improve, demolish, or repair any ,scruc ure
Pont its issadsce.also requires the applicant for such permll to fila.elgnel stammeal
an
p bat he is licensed pursut 1. the provisions of the Contractor's License Law (Chapter
9(commenclag with Settled 20W) of Division 3 of the Basin., and Professions Code)
do or that he is exempttherefrom and the basis for the alleged exemption. Any violation of
Y Section 2031.5by-1 applicant I.,.peth
rmitsubjecteeupplicmm.civilpenaltyof
net more than five hundred dollars ($500).
p� ❑ 1,avrwnerefthepmperty, ormyemp oyeeswith wages es theirsaec.a Ew, ti.n.
collide the work, and thesiruaura is not intendedomffereAforeale(Seo 2044,Businoss
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
cent VALUATION
I�
rt,UitrillryY
OUTLETS - SWITCHES - FIXTURES
NEWRESIDF.NTIALELECTR S .FL
Q
STORIES
and Professions Cade: The Contmmnt's License Law does not apply he an owner of
propeny whobuiidsorimproves thereon, andwhodoe+such work himselforthrough his
wnempleyaes, providedthat such impmvemenmarenot intendedorofferedfoceaie. If,
however, the building or improvement is sold within one yearofcempletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.)
❑ I, as ownendthe propedy.em exdusrvelyconvanmgwnhlicensed convane em
construct the pngect (Sec 2044, Business and profession, Code:) The Contractors
OCC. GROUP
ffAPN
TOTAL:
$
QTY `.PLUMBING PERMIT' o, G'
FLOODZONE
License Law does not apply to an ownerefpropeny who builds or improves thereon,and
PERMIT ISSUANCE
who contrams for such projects with ucommcfor(s) licemedpursuant to the Contractors
License Law,
❑ I am exempt under Sec. I& PC Jordan reason
ALTER - DRAIN &VEN'T-WATER RIA)PBG
SUMMARY "
ygCK FLOW PROTECT. pF.VICE
GO SIDE FEES
Y
OwnerSANITARY
Date
WORKMAN COMPENSATION DECLARATION ON
❑ thereby affirm lhmlhave a ecnificula of consent to self-i9� , eeenificule of
Warken'Cmd as lost BW co reo'$AWT—, abCJwhich
Policy# al l cuplolp'
(BUILDING
DRAINS- FLOOR, ROOF, AREA, COND.
_N
RECEIPT#
SCHOOLTAX Y_N
RECEIPfN
Fl%'TURES-PER TRAP
PARK ME Ycovers N
RECEIPT#
GAS -EA.SYSTEM-I INC.4ODU.ETS
DIVISION FEES
Cnmpnny.
GAS - EA, SYSTEM -OVER 4 (EA)
❑ -reified copy is hereb f
PLANCHECK PGE
Clarified copy i. o with the city ir,pectiea division,
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
C TIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATI INSURANCE.
GREASE TRAP
SOILS PP.F.
(Thisseed nneedambearm dif permit isforonelshoddolla (SIM)
ar les'.)
SEWER - SANITARY - STORM EA, 2WFP.
ENERGY FEE
Icenifyl tiothe performances rkforwh'h itis' ucd,Ishnll
not employ . pets is an so as to bee cot the Workers'
Compens.don uwe of if d are
Applica t
WATER HEATER W/VENT/ELECTR
PAID
Delo Receipt If
WATER SYSTEM/IREATING
NOTICETO PLICA,.flet a thus eniticuleof xemplion. yaushoald
became subjec la the W r. Comp (' aprovisions a d ab or Cnde, you must
forthwith corn ywith such tem (this pe.it sit eJeemed revoked.
NEW RESIDENTIAL TIME. SQ. FT.
TOTAL:
BUILDING FEE
CONSTRUCTION LEND] .AGENCY -
1 hereby of rat that there is a construction ading agency for the performance of
the work for whi thispormilisissued(Sle 092,Civ.CJ
Loaders Name
SEISMIC ME
'TOTAL:
ELECTRIC FEE
Lenders Aaamse
ave
I certify that I u read this licafon add state that the above informal an s
QTY MfdCHANICAL PERMIT', 7-7
PLUMBING FEE
PERMIT ISSOONCE Y/f
ULA
MECHANICAL FEE
rrcet. l agree to to with fly and county ordinances and stale laws relating to
builtim,e nnructim, an ymmlrnrlu represent.uveal[ this Gly to enter upon the
arty for inspection purposes.
(We) a, indemnify and keep harmless the City of Cupertino against
il.bililies,I IS Brsandexpcnaeswhiohmayinanyweyacorue eidets.id bWAIRIIANDUNGUNITT0IO"CFM1
uinwe-mentioned IV'
convey ne rat gefthi,parmit.
ALTER OR ADDTO MECH,
CONSTRUCTIONTAX
NDLING UNIT (TO IO,OWCFM)
NDLING UNIT IO,OpO CFM)
Signaturer t pareST
HOOD(W/DUC'O
PAID
G UNIT 10gW0 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanter future building occupant store or handle hdentom ematerin
pate Receipt#
as defined by the Cupcnine, Municipal Code, Chapter 9.12, and the Health and SafetG
UNIT 100,000 BTU)
Code. Sectio❑.
VENTILATION PAN (SINGLBAESID)
Y55m32(ayl 11 No
Will theapplicumorfnmmbuildingoccupam useequipmentordevices whichemi(
-COMP 3HP OR IOO,WO RTU
)hazardous
ATE
air conmunica es us defined by the Bay Area Air Quality Managemen
COMP (OVER I W,WO BTU)District'I❑
Yes ❑ Nn
SIDENTIAL MECIL SQ. FT,I
have Mae the hazardous materials requirements under Chapter 695 of the/
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility fo notify the
occupant of the requirements which must be at prior to issuance of a Collocate, of
Occupancy,
SSUF.D BY:
Owner or dummied agent - Date
TOTAL:
OFFICE