28279APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ll,)ING-ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PI.UMBINQ- MF.CHANIFIC
BUILDING I'RO.IECT IDRN'TIh'ICA'fION �
PERMIT NO.
28279
BUILDING ADDRESS
SANITARY NO.
APPPPILICATIONSUBMITTALDATE
UNIT It LOTq
rp$�
TOWN' NA�M�E:r PHONE:
[t.V
CON CYOR'SNA E; LIC NO:
NFC
❑
CONTROCis
. ARCHITECT/F.NGINF,F.R: LIC NO:
DD
D 9`3
CONTACT: PHONE i
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ECT PLUMB MECH
1❑
PERMITISSUANCE
❑ ❑
LICENSED CONTRACTOR'SD9C TION -
I hereby offron unit lam licensed under pmvk.,amad lthera9(cemarchimg with
Section 90W) of Division 3 afthi Business and Professions Code, and my license is In
APPLIANCES - RESIDENTIAL.
JOB DESCRIPTION l
PANELS
fullnse
�r
lndeffect
IAClass-
T come Close Lia#
UP T02(XIAMPS
Date Contractor
1000 AMPS
ARCHITECTS DECLARA'ON
YL
I I understand my plains shall be used m public records. ,
OVER
E
py13R 1000AMPS
SQ. FY. FLOOR AREA
$/SQ. EY.
SIGNS ELECTRICAL
Licensed Pro( clonal
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
Law for the
1 hereby affirm that 1 am exempt from the Contractors Co
TEMP. METER OR POLE INST.
followingreason.(Sermon 9031.5, e: Any
ainesnnd Professions Code: Any city or county
which o pmMt m construct, aper, Improve, d or any structure
t,
it, sw lrepair
pdonos t ri ,month,
lheapplicat permute Blerati
s ... Threat(Chapter
POWER DEVICES
five odmostaromres
that he is ns,nscd p Sectio m the provisions of The anntmcmn's License Law (Chapter
softhe Co Lad
Division 3ofthe Rusineasand.
9(wmhe iota Code)
SWIMMING POOL ELECTRIC
VALUATION
orthohe 131.5 by anya merchant.Toldfor a baspermitonbeasegedoxemant to A civil Penalty of
isexgmat mectian Told)he An,
subject the applicant tonoivil penniry of
Section7031.5than
OUTLETS - SWITCHES - FIXTURES
rat fee hundred &.1im,($500mit
Bol more than Flva hundrod dollars (§500).
❑
ofwagesm0ei(ec.
NEW RESIDENTIAL ELECYR _ SQ. FT.
STORIES
'1'VPE CONSTRUCTION
will dolhewons and theate cture is or 044,8 siren,
othev ser and the fered nsale Seo. 7044, Business
Candrebm's License Law
and Professions Code: The Contraeeon, License does ota
apply to an owner of
property nes or
bapervids limproves thded wshoder selfor rhmugh his
OCC URDU
RES. UNITS
imploywho
own employees.p improvndwho aressuch
intrtaccmpletiod tarsale.If,
ingorimurementisvementwithinne
howevmilder will
ihe llhave[lie maker
not build of completion, the impose of
builder will have [lie burden of proving that he did not build or improve for propose of
he
TOTAL:
QTY. - PLUMBING,PERMUF FEE
❑ I,asownerofOnepmperty,amexclusivelyconnaciingwilblicensedcanuacmram
FLOODZONE
APN
pusher The pmject (Sec. 7044, Business and Professions Code,) The Contractor's
PERMIT ISSUANCE
License Law does not apply marmeneroMeoperty whobuildsorimproves thereon, and
'
who commets forsuch projects with acomeacmr(s) licensed pursuant to the Contractors
License Law.
ALTER-DRAIN&VENT-WATER (EA)
"FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY YN
xECEII'Tq
OwnerDam
DRAINS- FLOORROOFAREAGOND
, , , ,
WORKMAN COMPENSATION DECLARATION
❑ IM1ereby aflinnTlmtlhave acedificam of wnsem mself-In sure, or aceaficateof
Workere'Compenmtionlmurunce nawrtificd dopy [hereof (Sec.3A00, Lah CJ which
SCHOOL. TAX YN
RECEIPT#
FIXTURES-PERTRAP
PARK PEE YN
GAS -GA SYSTEM-] IN440UTLETS
vers.111 Plqyey�made i
F011cyq /�C/C �J �
xECE1PT#
BUILDING DIVISION PEES
Cnn nJ, Ham—
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
B�Cn e-py is hereby famished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
enifed copy is filed witinhedty inspersion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE.
SEWER -SANITARY -STORM EA. 20BUT.
ENERGYft
(Thh,capaon need not be completed if Ne xionit is for one hundred dollars(SIM)
or less.)
WATER HEATER W/VENT/ELECTR
I ocardy that in the performance of he work for which this permit is issued, Ishall
not employ any person in any manner so as to become subject to the Workers'
Compensmion Lowsof CeliPomia. Date
Applicant
WATER SYSTEMrFREATING
(�(/�— Receipt#
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
becomesubject no the Worker's Compensation pmvkiona of the Labor Code,on m
yust
forthwith comply with such previsions or this pem , shall bemed o derevoked.
NEW RIS] DENTIAL FUND. SQ. FT.
UA'r TOTAL:
BUILDI-drPdl� „
CONSTRUCTION LENDING AGENCY
SEISMIC FEE U
I hereby affirm that here is a construction lending agency for the performance of
TOTAL:
ELECTRICFEE
The work for which this permit is issued (Set, 9099, Civ. C.)
Lender's Name
Lres
ender's Adds
QTY. MECHANICAL PERMIT, k FEE
PLUMBING HE
I certify Nut I have reed this aMinallh n and state Tho the above information is
PERMIT ISSUANCE
MECHANICAL NEE
correct. I agree to comply with all cityand county ordinances and state lows relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) socaft, save, indemnify and keep harmless the City of Cupertino agamt
Llobilides,judgmems, costs and expenses which mayin any way, aeemoagalnst said City
AIR HANDLING UNIT T 010,000 CFM)
in consequence of The granting of this permit.
AIR HANDLING UNIT (OVER I (TWO CFM)
Signature of Applicant/Contrantor Date
EXHAUST HOOD(W/DUCH
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam - Rwcipt#
Will the applicant or future building occupant store or handle hazardous material
as definul by the Cupertino Municipal Code, Chapter 9.12, and The health and Safety
HEATING UNIT(OVER 100,000 BTU)
Cade, Section
11 11 No
VENTILATION FAN(SINGLE REBID)
- Will the appliwmarPommrd
re building occupant use equipmen eviceswM1idn end(
IS„ NATK4
1'_
BOILER- COMP (THP OR 1011, 030 BTU)
zdo
arus on
air ctaminumv as defined by the Bay Arca Air Quality Management'
Uismid1
El Yet, 0 N -
1 hread the huzmdous materials reyviremetns under Chapter 695 of Om
Calif le fl ITh&Safety Code, Sections 25505, 25533 and 25534. Iunderetmdthat
if thboilldin does nomrren0y have arae nt, the I is my responsibility m notify Thefhquimme .smurceda Certificateof
0
C/nom' I 8 C
r/V�
BOILER- CAMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
i
ISSUED BY:
O raallemedagent Doe
TOTAL:
OFFICE