28155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO In I. 1 (..ELEL'I'RI AI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IIUILDING PR(1JKCT IIIRNTIFICATION 28155
SANITARY NO. APPLICATIONSUNMTITN.DAT,
GILDING ADDRESS: /���(( [/� ,rte O
NE elT/ LU /L� ����0 /UNITp OTk — �
O N14RSNAME: PHONE: CONRACTOR'S NAME: _
!� C NO:
Lr PL C C �- e,! 'Xzat �� N/C CONTROI,k
RCIIITLCI'/IiNGINIiIiR:
CONTACT: PHONE,: ? ❑
QTY. ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
1 BLDG E PLUMB MECH
P13NMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
000 the byaffimn thvtl ernlicensed underpmvisinnsofChepmr9(commencing with _ B�ETC Ip pT
ts100❑ a7 dn' is 3 of theBminess nnJ Professions Code,and mylicense is in PANELS
JOB
O JLIS"an'
VCJ 1 c ad ,
Z 4 Lic.p UP TO 2W AMPS
5 h n ass Comraror 201-ItNq AMPS
Z�N2 ARCFIITECPS DECLARATION OVER IIXXIAMPS SQ.PT.FLOOR AREA $/SQ.FT.
C YZ-O I understand my plans shall be used as public records.
K�< Wttnsed Rnfcasronel Lq SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Sd3LLI,- 1 hereby affirm that I um exempt from the Contractor's License law for the
uu11 Om following Mason.(Section 7031.5,Businessand Professions Code:Any eiryorcouity TEMP.ME-R OR POLE INST.
�,�
1}� which requires a permit m constmr,vher,improve,demolish,or repair any stmmum
wuFinalu nissuunce,also bovines the applicant fnrsuchperenitm fileasigned steamer, POWER DEVICES
K C O Net he is licensed pursuam ro the provisions of the Comnns
nors Litte Lew(Chapter
9(commencing with Section 7")of Di vision 3 oftbe Business and Professions Code) SWIMMING POOL ELECT RIC
m f,y
or he is excmpnhernfiomand the basis for the W119M excmminn.Any vichumbof VALUATION
I=2G Section 7031.5 by anyappliesto fora Fermi,subjects the applicant m a civil penalty of OUT1E75-SWITC11.. XTUso,
am moredam e an five hundred dollars($50(1). (45696a
� m ❑ I,mownernftM1epropenyormyemployeeswi,h wugexanheirsolecompcnsatinn, NEWRESIDENIIALF,LECIR
a will dothewour
rk,and the ocure is not incrdedoroffered fmssle(Sm,7074,Business STORIES TYPE CONSTRUCTION
and Professions Code:The Contramor's License Low does not apply to as owner of
Property whobuildsorimprovesthcrenn,undwhndoessuch work himselfor through his
owmmployees,Provided that such improvemcnBvre not intended rroffered Inside.if, OCC.GROUP RFS,UNITS
however,the building or Improvemem is sold within one ycarof completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of 1-
age.).
❑ I.Mownerofthe Property,amexclusivelycnntracting with licensedmirroscmrsto QTY' PLUMBING PERMIT FEE FLOOD ZONE omuuet the project(Sec.7044,Business and Professions Code:)The Contractor's ppN
LiceralawdtKan.Iapplyto an ownerofpropem,whobiddamimpmveeshemon.und PERMIT ISSUANCE
whocommets forsuch projects with a comb cards)licensed pursuant o the Counselor's
License Law. ALTER-GRAIN&V 'R EA)❑ 1 amexempt under Sec. ,B&P C for this reason FEE SUMMARY
BACK FLOW P ITCT,DEVICE SID•FEE.
Owner Date SANITARY Y-N
WORKMAN COMPENSATION DECLARATIONDRAIN , OOR,ROOF,AREA,CON RRCF.IPf4
I hereby uf0rm thmlhavencedificrc ofmmenuo self-insure,aracertifcatc of SCHOOLTAX
Wmken'Cnmpensation lnsumnce ora certified copy thereof(Sec.Jg00,Lob C.)which TURFS-PER TRAP RECEIPT
covers all employees under this permit PARKFEE Y__N__
Policy N GAS-EA.SYSTF.M.I INC.4 OUTLETS RF.CEIPI'X
Company BUILDING DIVISION FEES
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cori find copy is fled with the city inspection division. GRIASFJINDUST ,WA 'INTERCE
GRADING FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GRPASETRAP
COMPENSATION INSURANCE I SOILS FEE
1'mis seninn neeJ notbe cnmplemJ if th<Pemmit is forone hundred Dollars($1 ) S ER-S O FT less.) ,2p
ENERGY FEE
I codify that in the performance of the work for which this Permit is issued.I sh I WA' R TE NPP U.EC1'R
not employ any person in any manner so as,n become subject M the Work, '
Compensationlawsaf Cnlifomia. Date TINGPAID
YSTEM s
z Applicant Dat Be tp
z 0 NOTICIi TOA1'PLICANT:lf,afmrmakingthisCmiOcomof Exemptiom,youshould NEW DENIAL PLMR. SQ,FT.
(q become subject o the Workers Compensation provisions ofthe Labor Code,you must TOTAL:
� ? forthwith comply with such provisions or this Permit shall he deemed revoked, BUILDING .F
LQ o CONSTRUCTION LENDING AGENCY
Z) z I hereby affirm that Omre is It comsau"kn lendingagency forth,perfooramnf SEISMIC FEL
J O the work for which this pemdt is iaaued(Sm.3119],Civ.C.) TOTAL: ELECTRIC FEL
lander',Name
ULender's Address QTY. ANICAL PERMIT FEE PLUMBING HE
Cil 1 ccnify lust I have read this application and srm that the above information is
4 correct I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MF.CIIANICAI.FEE
y building construction,and here by nmhmim ecpresema,ives ofthis city to enmr upon the
J above-mempurp
ioned properly for inspection oses. ALTER OR ADD TO MECH. CONSTRUCf10NTAX
(We)a vet indcmmfy and keep hornless the City of Cupertino against
liabili,ic ' a nt,cossanticxpenseswhi may it,my way accrue against said City AIR HANDLING UNIT GO 10."CFM)
inn que a ogretmI w �Q
r AIR I IANDLING UNLT(OVLR 10.000CFM)
Signature..Applicant ommmor / the
�3 EXDAUST DOOD(W/DUCT)
HAZARDOUS MATERIALSccupDISCLOSURE HEATING UNIT(TO 1W,o0(10'NPAID) Dom RecciptM
Will the applicant or future building
txapam stow or handle haaaMous motorial
sa defined by the Cupertino Municipal Code.Chapter 9.12,and the Flealth and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)'t
❑Yes 0N VENTILATION FAN(SINGLE RESID)
Will the applicam"rf rime buildingoccup rm-sae BOILER-COMP(311P OR Hgk000 BTU) ISSUANCE DATE
quipmm�t ur devices which emit
vallous air conn nuns as defined by the Bay Area Air Quality Management s�
ismm7 BOILER-COMP(OVER 100,000 BTU) 1" q
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,PT. 4aV aD
1 have read the hazardous marerials mrriremeats under Chapter 0.95 of the 4
Califnmis Health&Safety Code,Sections 25505,25533 unit 25534, 1understand that UAe Q
if the building does not normally hover moan,that it is my responsibility to notify the 4 V
occupant of the mquhements which must be met prior to bounce of a Corti fere of C/�
Occupancy.
Owner ur umhonaA ager Dates,
TOTAL: ISSUED BY 140
OFFICE