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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - r.LF.TRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUIILDINGPROJFICT'IDRN'1'IFICATIN
PERMIT NO.
28145
BUILDINGADORESS:,/a,q jf '•f�/
SANITARY NO.
APPLICATION SUBMITTAL DATE
iiOOJJ GAA,PLFb)Cy;r ^/.
/ UNIT# LOT,
OWNERS NAMIi: Rn Ptl��/
Y
CONTRACTOR LIOC NO: Q
V'r Y 1s
N/C
El
CONTROLM
RCHITECT//E•vN/GINEER: LIC NO:
ADDRESS
31 A
CONTACT: PHONE:
J
&APICI� p119PSW I glr49— 9sd 1/
V" N
QTY. ELECTRIC PERMIT FEE
BU ILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El
LICENSED CONTRACTOR'S DECLARATION
Thereby ofDitealI umfthe uunder and Protesaiehapter and my license
Section 7") of Division laf the Business and Rofessiom Cock. and myliccnu is in
full force and eflot.
1 Lic. p f
Date �
Date 0r O.af�
APPLIANCES - RESIDENTIAL
PANELS
UP T0200 AMPS
JOB DESCRIPTION
201 - 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ.IT.
ITCTmS
ARCHITECTS DECLARATION
I understand my plana thrill x nae, as panba recarda.
OVER I" AMPS
SIGNS ELECTRICAL
Licensed Professional
/
SPECIAL CIRCUIT/MI
OWNER -BUIL ECLARATI
�-Y[
v`
1 hereby affirm that opt from the Canuun is License Law, for the
TEMP. METER &VLr INST.
followin ion 7031.5, Business and Professions ode:Anyciryoremmy
which r seines a permit or emtxlmc6 ulcer, improve, demer, , m repair any awcmre
Puerto Bissumn ,alsomqul Neapplicaatforsuchpermi to file a signed statement
POWER DEVIC
that he i licensed pursuant to the provisions of the Commcu 's License Law (Chapter
9m. acing widhSmien J000)of 'visi fNe Basin ss and Professions Code)
or that is escmpl therefrom and the dsi Ili al cde mption. Any violation of
Section 131.51, wryappli dto ra ubjima thea icanuoe<ivil penalty of
SWIMMING PoOLC C
VALUA ION
/ V� ��� '
e
OUTLETS-SWITCI TU
no, more than 0v hundred le
[I L. awl c empbyxswilhwag theirsolecompermada..
NEW RFSIDENTIAI. ELF: .14.
STORIES
'TYPE CONSTRUCTION
willful ewor Ih mi,nocinemiledmoff f aide (Set. 70,P1, Business
and Pro ession. a Chmanumrs License doe not apply to an owner or
Propert on0buildor prnvesthereon,andw doessuch orktimselforthrough his
costic Ioyeas,P of thauuchimpmv entsarenmimm�dedomfferedfursale.IL
OCC. GROUP
RES, UNITS
htwc r, the hull it rimprovemer, Id within one year ofcompletion,theowner-
build will hove the burden of pm g dead he did not build m improve for puryove of
QTY. PLUMBING PERMIT FEE
sale.
❑ Lmowncrofthepro y,umcxclusivelycontrctingwimlicenudcontmctomto
FLOOD ZONE
APN
con rust the project .. 701 Business and Professions Code) The Cmnracmrs
Lic nmlewdaes applytuanownerofpmpenywho builds urimpmu th
vereon.and
te pEItMIT' ISSUANCE
sk
wit corlaasf uch projects with acontramons) licensed purmam to the Contractors
Lic sola
ALTER IEA)
FEE SUMMARY
❑ exempt under Sec. , B & P C for this mason
BACK PLOW I'NOT'ELT. DEVICE
O ID' FE
SANITARY Y N
RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ 1hereby affirm that l have a cenificade ofcansom to selbinsum, or a certificates of
Wmkerd Compenmtion lnsumnce ora unified copy thereof (Sec, J800,Ieb C.)which
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX Y N
RECEIPT M
FT%TURES - PER TRAP
PARK HE Y N
cavern all employee's under This per of
Policy 0
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
TL
RECP.IPfa
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4BA)
PLANCHECKIEE
❑ Certified copy ishemby famished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenified copy is riled with the city inspection division.
CERTIFICATE OF 17XEMMON FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE O
Gras section need not be completed ifthe permit is far one hundred dollars
witless)
WATER HEATER W/VENT/F.LECfB
PAID
I cenifylhm lathe perfmmmeatifthe work for which this permit is issued,I shall
nod employ any person in any manna so as m become subject a the Workers'
Comnsat
peion Lowsof Califnuia. Dade
Applicant
WATER SYSTEM,7REATTNG
n
] — Rtteiptg !'I
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEWRESIDFNTIALPLMB. SQ.FT.
TOTAL:
become subject o the Workers Compensation provisiom of the Labor Code, you must
Forthwith comply with such provisions ar this Formic shall he domed revoked.
BUILDING FEE
CONST'SUCTION LENDING AGENCY
SEISMIC .�
I heeby affirm that hem is a construction lending agency for the performance of
the work for which this permil Is issued (Sec. 3097, Civ. C.)
Landers Name
TOTAL:CTRIC
FIi
Lender's Address
QTY. MECHANICAL PERMIT
cmify Nm 1 have read this application and stall that the above informaton isC
Iagree to comply with all city and county ordinances and state laws relating do
PERMIT ISSUANCErt
N L FEEmem.
ubov(We).9mensave.yfee
EFEIEPLUMVINGIVAI
ALTER OR ADD TO MECH.
U ION AX
mnify std keep has.
1 We) agree against
save, indemnify and kap harmless the City of Caganst
nt
liubllitics,judgments, cues and expenses which may in any way accrue against said City
s
AIR HANDLING UNIT (T010,1100 CF
inconsequence of the gmnling of `Itis permit.
as�
AIR HANDLING UNIT (OVER 10,000 CFM)
Sigumme, of Applicata/Camracrore Date
EXHAUST HOOD (W/DUCI)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Us Nccciplk
Will the applicant or future building occupant store or handle harerdous material
an defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HGTING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESHB
Code, Section 25532(,)1
❑ Yes ❑ No
Will the appmmunalt or nes building by the Bay Area Ain Qualitc Managementh emit
es rdous air communal os defined by the Bay Arne Air Quality Management
istrictl
BOILER - COME (3HP OR 100,000 BTU)
ISSUANCE DATE
^
(� LI
BOILER - COME(OVER 100.000 BTU)
❑Yea 0 N
I have maare
d the hrefous materials requirements under Chapter 6.95 of the
NEW RESIDENTIALMECII. SQ.FT,
1d ����
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building dos nm currently have amanl. but it is my responsibility to notify the
occupant of the requirements which must x met prior to issuance of a Cenifiesta of
�' ser �UN u
Occupancy.
ISSUED BY:
Owner or,mhodeed e8cut Date
OFFICE