28139 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING'ELECTRICAL PERMIT NO.
APPLICATION/PERNIIT PLUMBING-MECHANICAL rT p n
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION GO J
BUILDING A ROESS: �Q ` DNITM LOT# SANITARY NO. APPLI^ON SUBMITTAL DATE
OW MF. V` PHONE: CONTRACTOR'S NAME: e-- NIC CONT S
1P I'l
ARCHITE ENG EER: LICNO: ADDRESS n � , b •' ❑
0V
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
vBLIND ELECT MOVE MECE
✓a"w^'l/ / ` PERMIT ISSUANCE 1VL �Gtt�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IfJJOB DESCRIPTIL�OTN
Q9z I hereby affirm that l um licensed under provisions ofChepter9(co uncraing with
Fl00 Section s ord of Di 3.f the Business and Professions Code,end my license is in PANELS
full Scott.me010).fDi rf�
6Vz� License Class Lick-6&-rDS UPT02MAMPS
ti 6 y Date - Contractor 201-1000 AMPS
zOyz ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA - $/SQ.EL
O z '1 understand my plans shall ba used as public recoMs. ���O `�
f=rnJ SIGNS ELECTRICAL
�d Lloensed l4ufcsxional
aYiT U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �,y
'Ji "' 1 hereby affirm that I am exempt from the Contractors e:Any Law bathe _`
W✓�C oaI following reason.(Benita]031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
�s �.] which requires a permit to construct,aheq improve,demolish,or repair any struc,.m
prior to its issuance,alsorequires the applicant forsuch permit to file a signed statement POWER DEVICES
AOm that he is licensed pursuant to the provisions of the Commetors License Law(Chapter -
eq 9(commencing with Section]00(fiof Division 3ef the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
❑,� 8 h70315mprtherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 0 �
>' Section]031.5 by any applicant far a permit subjects the applicant to a civil pcarry of
0 not more than five hundred dollars($500). NEW RESIDENTIAI.ELECTR —SQ.FT. 1
S3� ❑ 1,asownerofthepropmry,ormyemployeeswithwagesastheirsolecompenation, STORIES TYPECONSTRUCf10N
will do the weak,andthestmetute is not incendedoroffered for sale(Sec.7044,Business e
and Professions Code:The Convector's License Law does not apply to an owner of
property who ba i lds or i mproves thereon,and who does such work hi easel f or through his
own employees,provided that such improvements aro not intended ormffwad far sale.If, OCC.GROUP MS.UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.), QTY.7ALTER
PLUMBINGPERMIT FEE FLOODZONE APN
❑ 1,as ownerofthe pmpery,am exclusively convecting wit conwmor to
mnswct the project(sea.71194,Business and Profession ode:)The ntctotrr's
License Laseduesnucipplyto an ownemfpropertywholb ds orimprovice the ,and ISSUANCE �
whocommcts fmsuch projects with.mom nta)lie Mpursuantmthe Convn tors DRAIN&VENT- ) FLE$UMMARY
License Law. WATER III r
❑ 1 am exempt under Sec. ,B&P C for this naso BACK FLOW PROTECT.DEVICE - OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT# '
WORKMAN COMP ATION DECLARATION SCHOOL TAX Y
❑ Ihembyaffirnthatlhaveaceni ate ofcnnsem[o self-ineurc,ore certificate of ORES TRAP RECEIPT#
Workers Insurance certified copy thereof(Sea.3g00,Lab CJwhieh PARK FEE Y N
covers all employee's under this m1i[' S-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT If
Policy# _ BUILDING DIVISION FEES
Company GA LA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is here Pomiehed.
❑ Certifiedeopyis files wititur city inspection division. GREAS54NDUSTRI,WASTE INTERCEPTOR GRADING FEE ��
CERTIFIC TEOFEXEMPTIONFROMWOR EASE TRAP SOILS FEE 4
OMPENSATION IN URA C
(This section need no eemnpietedlOhep it ere¢d ($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE tt�i•
unless.) `
Icertify[hatirtheporf armcifthew ch flu hisissued,I eB WATER HEATER W/VENT/ELECTR
not employ any person in y mamter so as to om bjccI to the kers' PAID
Z Compensation Lews of Califo ia. Date WATER SYSTEMTREATING Date Receipt#
p O Applicwt
NOTICE TO APPLICANT:If, termaking this Certificate of Lxem n,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t-I y become subject to the Worker's mpensation provisions of the l.a rCode,you must
Lam. ; forthwith comply with such to ionsna this pemtit shall be d ed revoked. BUILDING FEE �1r
W (] CONSTRU ION LENDZAGC SEISMIC FBE
Iherehyuffimttheuhere is a c nstruction lfur[he performance of F.LECIRIC PEE
O theworkforwhichthispermit is issu (Sec.3117-11AW 167
Lender's m
Nue
U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is — IDE
a correct.In to comply with all cit MECHANICAL FEE
gree pyhereby
e city state ender
atin the PERMIT ISSUANCE
buildingcmnsmed property
hereb inspection
ofthis city to emerupon the CONSTRUCTION TAX
lsswt 47
[J7 above-mentioned propertyfor inspection keep La a ALTER ORADD TO MECH.
1�- (We)ogres d save,Indemnify and hoc harmless the C' of Cupertino ma[
incoisiequenc offin cratering ex pens es unit. may' ywe c inn iJ Cit AIR HANDLING UNIT(TO 10.000CFM)
consequence of the granting of this permit.
r AIR HANDLING UNIT(OVER 10,000 CPM) -
Signature ofA icanUContracmr DVc EXHAUST DOUG(W/DUCTJ
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,W0 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous national
n defined by the Cupertino Municipal Code,Chapter 9.)2,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)7
ElYes El No VENTILATION FAN(SINGLE RFSID)
❑
BOILER-COMP(3HP OR Eff,"BTU) ISSUANCE DATE
Will[heapplicant
or futurehuildingoccapant useequipment ordevices whicherdt ' D
azardous air contaminants as defines by the Bey Area Air Quality Management BOILER-COMP(OVER IOO,WO BTU)
isuim]
❑Yes ❑No NEW RESIDENTIAL MELD, SQ.En _
. I have read the hazardous materials requirements under Chapter 6.95 of the JUN 281995
California Health$Safety Code,Sections 25505,25533 and 25534.I understand that /�
if the building does not curently have.tenant,that it is my responsibility,.notify the CII Y Ur GurC
�t�i�
ccupam of the requirements which must be met prior to issuance of a Certificate of
occupancy.
Owner or amhomed on, Date ISSUED
OFFICE