28148 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
UILDING ADDRESS:
BUILDING PROJECT IDENTIFICATION
28148
SANITARY NO. AP/L�CATION SUBMTITAL DATE
rye a+_ /2 .Q TO .. o --�-Gl�
NIT N OT p
WN[RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CONTROLN
AKc.UHLCI7EblGIN1iER: LICN ADDRESS: /
CONTACT: PHONE: ❑ ((—
QTY. ELECMiC PERMIT FEE BUILDING PERMIT INFO
BLDG - ELECT PLUMB MECH
PERMIT ISSUANCE trif, [3El 11LICENSED CONTRACTOR'S DECLARATION gppLIANCES-RESIDf3M1'IAL
WCz I hereby affirm that I am licensed under provisions ofartmer9(commencing with JOB DESCRIPTION
LL00 Seetion7")of Division 3 of the Bulinus and Professions Cade.and mylicrnseisin PANELS
FK V� full tome and effect. ^— -
FLicense Class Contractor UP T02W AMPS
/ s\1J�1/'sL�1w!'1
Tr-Q L Dale 201-10M AMPS
Z Oyu _ AREC DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA - $/SQ.FT.
O_ ]understand my plena sh.11M1ull he uxd as public reroNs.
~"1= SIGNS ELECTRICAL
IW J Lm...----sancnul
�K < OWNER-0empt fm
d he ORATION SPECIAL.CIRCUIT/MISC.
�'O a V I hereby nffvm that 1 em exempt from me Contacmre License Law for the
W�+O,iFa following rcavon.(Septi.7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
'which acquires u permit to construct,eller,improve,demolish,or repair any structure
tyWa2 prionoin issuance,dao requieas"alpplicanlfarauch i0ofileasignednmemem POWER DEVICES
W�'
00 thm he is licensed pursuannn the provi..orn of the Cn n r'a License Law(Chaprer
L50 9(mmmcncing with Scemion]W0)of Division3aR Basin and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ly_y legedeae ti
orthet he is exempuherefrom and the basis forth on.Anyvialmiono(
i Sermon]OJ LS by any applicant fore permit su acts thea Ira to Of1TLET5-SWITCHES-FIXTURES
0 r more than five hundred dollars($500). PF Penalty of
❑ I.mownerofiheprowery.ormydmp eawithwagesvtheirs ecompen.ation, NEW RISIDENTIALELECB _SQ.PT. STORIES TYPE CONSTRUCTION
o. will do the work,medicsmuctumisnnli endedcaofferedforsale(Sec. 044,11miness
and Pmfe.sions Calc:The Contract s License Lew does nm apply t nn owner of
propenywhobuildeorimprova ,mcwhodeersuchworkhimulf ughhis
own employees,providedthm: impmvemenw me nofimended proffered reale.If, OCC.GROUP RES.UNITS
however,the building prim vememia uldwimino Y Bfe pletion, owner-
builder will have the burden proving Ihat he did not noa for p u of AL.
sale.). I
[01Laowno,fdopropmy, exclus 'Nlicars directors to QTY. PLUMBING PERMIT E ROODZONE qpN
comm at the project(Sec.70M, aline ssions Cade) Contracmts
License
Law does not applytu ado end whobuildsorimmP�moves thereon,and PERMIT ISSUANCE
whoamtmcufnrsuchprojeenwima-antr c Iicensedpura lactmo Cond.eme.
License Law. ALTER-DRAIN&VENT-WATER( FBE SUMMARY
❑ 1 am exempt under Sec. &P C for this reason
BACK FLOW PROTECT.DEVICE SI
Owner Date SANITARY Y N
WORKMANCOMPEN POND LARATION DRAINS-FLOOR,ROOF,AREA,CO.
RECBIPTk
EIIhcreby off thatlhavencedificm fconu Id self-insure,oreartifinete of - SCHOOL TAX y ry_
Workers Compemmionlnsumnceoracenim co
m<rcof(Sec.Jg00,Lab C.)which PIXTUR[S-PER TRAP RECEI
lis all employee's under this permit. PARK FEE Y N
Policy GAS HA.SYSTEM-1 INC.4 OUTLETS RE -PTs
Company ISIO ES
❑ Cmified copy is hereby famished. GAS EA.SYSTE M-OVER 4(FA) PIANCHE
❑ CeniR<d copy is filth with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADI G
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE S
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM P.A.200FT. HN pR
carless]
I codify that in the perform.,drhe workforwhich this permit is issued,Isbell WATER HEATER WNFNT/ELfiCIR
not employ any pens in any manner so as to become subject to the Workers' PAID
z Compensation Lawsnf Califomia. Date WATER SYSTEMITRFATING
ApplicDataReeApplicant,
NOTICE TO APPLICANT:If,after making this Certificate offisemplion,you should NEW RESIDENTIAL PLMB.uSQ.FT.
fq become subject the Workers Compcnsetion provisions of Ne Lobar Code,you must TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked. BUILD GFEE 0�
LTa Q CONSTRUCTION LENDING AGENCY SEISM FTE
z I hereby affirm that there is a consumption lending agency for the po feemence of \
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRI E
Lander.Name ,
0 U Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING •E
} W 1 cemify that I have read ria application ane arm that me above information is
0. correct.lagreemcomplywithnllcitYer uatymdinancesmdsMn lawsmlatingm PERMIT ISSUANCE MECHANICAL E
� building construction,and hereby authorize representatives ofthis city tocroptipon the
(, Z move mentioned propeny for inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTION X
(We)agree to save,indemnify and keep harank as the at,of Cupcdina against
Iiabilitics,judgmenes,costs and expenses which may in any wayuccom.1inm said City AIR HANDLING UNIT(TO 10,1101)CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) D
gdalure of Ap UCono-nor Da EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISL.OSURE HEATING UNIT(TO 1011,000 BTU) DmE c tM
Will by he C-wm or tumor building occupant er 9.or handle hazardous dnredel
Code.Sedco the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER IOO,IXp BTU) TOT
Code,tiection 25532(u)7
❑ TICITY
Yee ❑No VENTILATION FAN(SINGLE RFSID)
Will theapplicnd arfummbuildingoccupanmseequipmntordeviceswhich emit BOILER-COMP(3UP OR IOQ010 BTU) ISS AN ATE
uardom air contaminations as def ed by the Bay Arts Air Quality Management BOILER-COMP(OVER 100,000 BTU) [/
rtia]
El Yes 11 No - NEW RESIDENTIAL MECIL SQ. T. C// 1995
I have read the huzerdous materials requirements under Chapter 6.95 of the Vr
Cnli1'ornia Health&Safmy Cale,Sections 25505.25533 and 25534. 1 understand that Vrl', L�/�
if the buildiag does not cu rreally have a teream,that it is my respornibility m notify the r l O
occupant of the requirements which must be mu prior to issuance of a Certificate of
Occupancy.
Owner m.whodud agent Dme
TOTAL: ISSUED BY:
OFFICE