28391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLHC'I RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� /�
BUILDING DIVISION i BUILDING P120.lECTIDENTIFICATION ; L83y
BUILDING ADDRESS: - SANITARY NO. APPLICATIONSUBMITI'ALDATE
/0/75_ 4006400f�9 Caf'f�nn.D, C/r' 9S-0#2 _
OWNERS N�MQE:.�' I C /'� PHONE: G/l COIM/T/D#tq,.CTOR'S NAyME`,x LOT#
/'�/W-��r ///Au �1�� /(/V 4�/�w�✓+KH SY JS NEC CONTROLp
RCHITF.CI'/RNGINEER: 2V LIC IS G ADD
IV �I L! ❑
IJ 7
CONFAC3': PHONE: QTY. ELECTRIC PERMIT - 1•'EE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE 32 Q
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL, C
C04Z, I hereby affirm that l am licensedunderprovisionsofChapter9(comemosing with JOB DESCRIPTION
[4 00 Sectim70o of Division Sof the Business and Professions Code, license is in PANELS
full fora end effe ,
Qz W License Class ^2� Lic# Ol UPT02WAMPS -
h a y Unte Commerce 201-IOW AMPS
ZO;Do` ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FLFLOORARFA $/SQ.F
O Z..G I understand my plans shell be used as public records
r:w lli SIGNS ELECTRICAL
<Stp..I Licensed Professional
Rce:ty�U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 hereby sffimr that I am exempt from the Contr'actor's License Law for the
u1a0m following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
E"pJ which requires a Permit to construct,alter,improve,demolish,or repair any structure -
NY� priorto its is.eared,also regmres the applietan boor Inch permit tofilie signedsta¢ment j POWER DEVICES '1
Q0that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter `°'aa
L . 9(commencing with Section 7000)of Division 3 of the Business and Profrssions Code) SWIMMING POOL ELECTRIC VALUATION
XW_,r>s or See,Ul he 3exempt
coloefrom and the basis for the alleged exempt on. civil prcultyof OUTLETS- — W
4C Section 3L56ymyapplicantfar apermil subjects he applicamroaeivil penalty of SWITCHES
not rethenfivdhundred doll ars ydelp NEWRESIDENTIALELECTR _g FT.
0.�',-„� I,eeownerofthepmpeny,nrmyemployecs with wages as their sold compensation, Q STORIES TYPECONSTRUC'I'ION
a 3._ will dmhewons and the he Coeienorinrcndede Law
sal apply to
owner
LEG—
and Professions Coda The Contmcrods License Lnw does not apply fo an owner of
property who builds mangroves thereon,and who does such work himself or through his
con employees,provided thatsuch improvementsaren.t imendedoroffdfed forsald.If, OCC.GROUP RES.UNITS
however,the building orimprovemem is sold within one yemofcompletion.the owner- TOTAL: _
builder will have the burden of proving that he did not build or improve for purpose of
3
a❑)Las owner ofthelimpidly,son exclusively computingwth licensed contractors to QTY;-r * .fP�UMBING PERMtR P >d<1704',f
FL Tp FLOOD ZONE APN
.nmmct the project(Sec 7044,Business and Profess ons('ode.)That Committers
License Law does notapply to an ownerofpreperey who builds or improves therein,antl PERMIT ISSUANCE
who contracts for such projects with acontrachads)licensed pursuant to the Contractor's
LieenseLaw. - ALTBR-
DRAIN&VENT-WATERCA) c{ ekd,j(cErSUMtv1ARYk ns ��•r z?n-
❑ I eem
m exempt under See. ,D&P C for this 1easan BACK FLOW PROTECT.DEVICE OUTSIDE FEP.S
SANITARY Y_N_
Owner, - Dale RECEIPTIf
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
Ihembyaff6mtbml haveacsllirlwteofcvnsentioself-insufe,oracatifieafe.0 PIX'I'URBS-PER TRAP REC91Pf#
Workers'Compensedoninsurnnoeoracertifiedcpyfloodf(Se.3800.Lab C.)which PARK PEP. Y N_
covers all empfIapr�e�e's under Nis�ffm't. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
C❑ompCertany ified copy Is hereby famished. GAS-EA.SYSTEM-OVER 4 BbO PIANCHECK FEE
-
❑ Ceaifled copy is Bled with the city insptminn division. GREASE/INDUSTRI,WASTE%T GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE A SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Hog,permit is forces hundred dellaT($IWt .2 6NP,RGY FBE
.rmss)
Icenify that in the perfmmanee of the work for which this permit isisadad;Ishal „WAT' .R T -
net employ any perm.in any manner so as to become subject to the Workers ° PAID
O z Compensation Lawsof Coliforms. Date .WDA R T6 TING Dale Receipt le
C—)
Applicant -
zz�-I NOTICE TO APPLICAN'T:Ifafler making this Certificate of Exemption,you should SQ.ET. TOTAL:
F-' CO become subject to the Worker's Compensation provisions of the Labor Cao,you must
; forthwith comply with Inch provisions or this parol he deemed revoked. BUILDING FEE 7
4 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE O
Zhereby affirm that truction lending agency for the performance of
L) O the work for which this permit is d(Sec 3097Civ C) TOTAL ELECTRIC FEE ,^
Lenders Name to V
F I.enders Address QTYrk'^,# x MECHANICAL PERMIT #'P�p# S FEL X' PLUMBING FEE
�^ W I cenify that 1 have read this application and some then the above mfortnati ed is - "'LT u r e%v
correct.I agree to comply with all city and aunty ordinances and state laws mladngto PERMIT ISSUANCE MECHANICAL FEE
sF^y V) building construction,and hereby authorize representatives ofthis city to enterupon the
above-mentioned rt for inspection CONSTRUCHONTAX
U 7 property pec ton purposes. ALTER OR ADD'f0 MECH.
(Wa)agreectsave,s and expeand keep mayinsthe City of Cupertino id Citt
liabilities,judgmentsecosaand expenses may in any way accrue against said City AIR HANDLING UNIT(TO IO,INq CPM7 7,
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicant/Comraomr Date EXHAUST HOOD(W/DUCT)
PAID V�
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,OW BTU) Dam Receipt#
Will the applicant or future building occupant smile or handle hszardous mmenal _ s ^�
as defined by the Captain.Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 RTU) z TOTAL:,,0`7q
C.Ae,Section Y532(e)] El No VEN9gLATION PAN(SINGER RBSID) P A 10
BOILER-COMP SHEDS 103,000'TO) ISSUANCE DATE
Will theapplicamorfuwrcbulldingoccupwtuseegWpmemordevlceawM1ichemit ( ) AUG �� ����
hazaMoue air ommminants as defined by the Day Arca Air Quality Management BOILER-COMP OVER 100,000 BTU
DGtrmet] ( )
❑Yes ❑No NEW RESIDENTIAL MECII. SQ,ET.
L have read the hazardous materials requirements under Chapter 6.95 of the CIT y Ur GuPER i INU
nia Ilealeh&Safe y Cwle,he 2550 5533 and 25534.1 understand that
uilding does note m Ihnt ie is my responsibiliry mno[ify eM1en,of the men naso be met prior to issuance of a Certificate of
ancy. zedagcan Date TOTAL: D15 Issued BYDo— p— tq�/1.>'f-C.ICC r
OFFICE