28290 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ �a ^ ^O
APPLICATION/PERMIT PLUMBING-MECHANICAL L 8 L l9J
BUILDING DIVISION BUILDING PKOJECT IDRN'riFICATION
BUILDING ADDRESS: 2 5� SANITARY NO. APPLICATION SUBMITTAL DATE
V ZV c> BV'v �V UNITia LOT IT 8��s
OWN PHONE: CONTRACTOH'SNAME: LIC NO:
( -' WILy-il—tv N/C ^CONTROL#
ARCHITECT/EJJGINEER: LIC NO: AD ESS:
lY,�
CONTACT: PHONE: BUILDING PERMIT INFO
`i tcS 54 3 132(0 QomELECTRIC PERMIT FEE
IqLgQ., ELECT PLUMB MECH
Ye�A - UC4 e �9C{f} � PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL RI N
muz Ihcmbyaffirml ti mlicros underprovisionsof Chapter9(commmcingwith
0100 e and of5pat.
IScrair IT 7")of Divisian3 of the Business and Professions C��'yl icenu�/i}in PANELS .
<z' Lacers h a s O Lic.p SS / UP TO 2W AMPS
m<y Dam Cnmmctor 1 201-1000 AMPS
F BiZ ARCHITECTS DECLARATION SQ.f?. DOR AREA S/SQ.IT.
Z066— 1 understand my plans shall be used as public records. OVER IIX0 AMPS
oz-0
SIGNS ELECTRICAL
Wgryytes.II Licanaed Professional
N OWNER-BUILDER DECLARATIO SPECIAL CIRCUIT/MISC.
igqi550'WU 1 hereby affirm that 1 an,exempt from the Carol. S Lac to Law far the
t++30 res following mason.(Section 7131.5,Business and Professlo Codc:A ycitymcounty TEMP.METER OR POLE INST.
��h� which rcyuira a permit to construes,atmq improve,de olish,or u r may swctme -
}� Frictions issuance,alsorequims the applicant for so permiuofilees Mincemeat POWER DEVICES
.'<0 that he is licensed pursuant to the provisions aft onnector s Licen Law(Chapter SWIMMING POOL ELECTRIC
IT,So� 9(commencingwith Smtion7g0)ofDivision fthe Businessand Pro asam Code) VALUATION
WMm at that he isexeritaimaefromand thebasis the alleged exemption.A vaolationof
6 Sectann J03L56yanyapplicantforape Osubjectsthcapplicanw.ri 'Ipenaltyof OUTLETS-SWITCHES.FIXTURES �
not more than five hundred dollars ). xlw
m [01ny I.somene,.fthepropcyemployeeswithwagesa`s)h4rsoleco persualm. NEW RESIDENTIAL ELELTR —SQ.PT. cSTORIES TYPE CONSTRUCTION
a3-2 will&th,work.andthe mehi mtamertdedmoffnedfa,is Sac.T Business
and Pm&ssio :The Contractors Lice se Ltiw,ioe'sTnoia�ply to as r of
prox,o,wI, ildsont Torces eteo rimpr andw o a"uc__M1�J,[[Is anselfonhroughhia OCC.CROUP RES.UNITS
ownemployce. ovided that,. em 'a 1lfas rdred torsade.If,
however.thcbu inrn
gorimpve d "a ` or 9yword tphana,theowner-
buitder will bve ch of id m(buald improve for pampa.of
ale.).
❑ Lasownero upon rty,a a huav8ycomat gwiNliansedeaaaacrursto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the praje (Sec.]014' as ea and Pt ssions Code:)The Contractor'$
License Lowdas not pplyto_.no a fpropc hnbuildsmimprnve llsomogand PERMIT ISSUANCE
who contracts for such rojectswim counter s)licreadpunuurrodoc Commcmr's
License Law. pC1ER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l um exempt under'ev. ,B At P C for this lemon BACK FLOW PROTECT.DEVICE OUTSI -
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF, GOND. RECHIPI'#
WORKM C PENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm thmlha reni0cam nfcnnsenno self-inarc,ora certificum of FIXTURES-PER TRAP RECEIPTp
Workers'Compatterion les s. ce nraceniOeJ wpy thereof(Sec.3500,Iab CJ which PARK FEE Y N
I wers aIle ncr i"p -Est.SYSTEM-I INC.4 OUTLETS RECEIPI'p
Policy# o ` BUILDING DMS FEES
CanY A)GAS- .SYSTEM-OVER4(EPLANCHECK FEE
rifled copy is hereby famished.
Cenificd copy is filed with the city inspection J........ GRGAS NDUSTRL WASTC••INTI?RCGPI'OR GRADING FEE
CERTIFICATE,OF EXEMPTION FROM 'RS GRL'AS TRAP SOILS FEE
COMPENSATION INS E
(This well=need not be completed if mtit is far..handled dollars IS 100) SEWER SAFRTARY-STORM EA.2001T. ENERGY FEE
or less.)
I cenifythm in the pert ceof the work for which this permit is issued,)shall WATER EATER WryLMf/ELECTR
not employ any person any manner nn es m become in 'est to the Workers' PAID
Cooperation laws of lifomie. Date WCfFERS STEM/IRGTING Dam Receipt#
Q Z Applicant
yzr�s-1 NOTICE TO APPLICA T:If,attar making this Ceti o cs prion,you should ENTIAL PCMB. SQ.FT. TOTAL:
t" E become subjed to rhe W essC pcmain p on cL.bo must
�i faMwilh comply with su prnvis as r is a.hallbedecm ra J.
u BUILDING FEE
Q CO LENDINGG Y� SEISMIC FEE
z IherebyaffirmN run asac coon le �yfarthepertmon TOTAL: ELECTRIC FEE
1, O the work for which this R it ie issu s ec 3692 ' )
W P lender's Name PLUMBING FEE
Lender's Address QTY, MECHANICALPERMIT FEE
LUZ7 I certify that 1 have lej1hispplication lication and state that the above' mon.lion is MECHANICALFEE
rrcn.lugrce mcomply ertd county oNinances enJ stet aws rel.tingm PERMIT ISSUANCE
buildingcoxwcdan,wdhrizertpraentafiveaoTunis ' mater upon the CONSTRUCf10N TAX
Vabove-mentioned property on purposes. ALTERORADDTOMECIL
(We)agreemsave,ind kap harmless th ny of Cupertino againstliabiliti 'sed menrs,c veswhichmay in rorueugain said AIR tIANDLING UNIT(TO IO,g16CFM)in ,eq n .f the rupetmi
AIR HANDLING UNIT(OVER 10,M)CFM)
Sign ureof Appli tractor ate EXHAOSTHOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,1100 BTU) Data Receipt#
Will the applicant or future building occupant atorc or handle hazardous material [TENTING UNIT(OVER 100,0(1(1 TO T
as defined by d penin Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Sectaan 532(a)P VENTILATION FAN(SINGLE RPSID)
Yes ❑No p
Willtheepplicanmrfumrebulldangacupamuse equipmcmardeviaswhichemit
BOILER-COME(3HP OR IOgOW BTU) Et. IS 11ANCE DATE
BacaDistnP s air r.am rate. . defined by the Bay Area Air Quality Management BOILER-COMP(OVER I W,fl(10 B'I'U)
11 Yes No NEW RESIDENTIAL MECH. SQ.IT. SEP 1 199�``ll
1 have read the hnmtdous materials roulmo mems under Chapter 6.95 of the �IVI'tl{�INV
California Heahh&Safety Code,Sections 25505,25533 and 25534.I understand that rI' Ur
if the building does not currently have a tenant.that it is my responsibility to notify the V
Ocupam of the requirements which must be met prior to issuance of a Certificate of
ccupancy.
Owne mialchorixedagent Data TOTAL: ISSUEDBY:
OFFICE