28257 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 28257
BUILDING ADDRESS: , A ,
r/r,4O SANITARY NO. APPI.ICAT��TIIaaa��, ///.TTT
ONS�UBMITTALDATE
OW/ONzz2 RmEn/PHONE. COIT RACfGR'SNAME: LOTM LIC NO:
fir I N/C CONTROL k
RCHITECT NGINEER: 49 LICNO: ADDRESS: ❑
nNTACT: - PHONE: - HU! IL DING PERMIT INFO
(,VO� QTY. ELECTRIC PERMIT FEE
�� / / 1 N��j'►� "7� ���Q PERMIT ISSUANCE LD ECT UM ME❑CH
LICENSED CONTRACTOR'S DECLARATION pppL1ANCE5RF.SIDENTIAL
I hcmb afr,.that lintllcen.edundw p ( ger JOB DESCRIPTION
qCZ y provirofesionsCter 9 dmmencin lin
[�i100 Semicon]000)df Divieion3 of the Bosincas and Professions Code,and my license is in PANELS
Poll force and effect,
F License Class t Ice.#_ UP TO 200 AMPS
it, Date Comme ar 201-1000 AMPS RIMT
z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLUOR AREA $/SQ.FT. .
OZ—C 1 undersmnd me us
y plane shall bed as puhlic mN
cos.
rry41 SIGNS ELECTRICAL
9 Licensed Professional
OWNER-BUILDER from
mEhe Conn..,
onn ION SPECIAL CIRCOIT/MISC.
yy O a U I hereby n.(So that I am exempt from the Co cions Co License Law for the
dxi13 W y following reasaa(Section]031.5 Business and Professions Cade:Any city or
structure TEMP.METER OR POLE INST.
J which requires a pends[to construct.ahem improve,demolish,m repair any structure
QC) pat 1.he
lisswed prsunttotth theapplicantofar the Chpermi,to's License
La smtemenl POWER DEVICES
a yy q that he is licensed pursuant to the provisions df the Ce But ass License Law(Chapmr
Wn 9t hat(commencing
xemwith
therefrom
and the
0(1 Division Sof the Bu' ass and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W—m Se h70315 mpuherefromamdthebasisfortheolle ex ption.Any violation of OUTLETS-SWITCHES-
G
Se 70315 anyd2ddonlrs($50rmid shbjed eeppli nuoucivil ¢ f FIXTURES —��
not mate[hen❑vo hundred Aallere($500). Pena y o
❑ Lasowderofthe n NEWRESIDENTIALELEC R _SQ.FT.
propstuermytionch ithenedaasth rsalecompeasodnd, STORIES - TYPE CONSTRUCTION
S3— willdOthewonsCde:Thethe cmreiachers en ve Laeredirm lytam,ovancrss -
ond Professions Code:The.es t ate.s se Law uch nw a ly lf an owner of
prupeny whohuildsorimproves thereo ,and whodcessuch work hi elforthmughhis
wnemployees,providedthatsuch' provememtsmanotintendedor fimmulforsale ff, OCOGROUP RES.UNITS
however,the building
.1impso end is sold within one yemofcom lichan,thaowner-
builder will have the bur of p-ving that he did not builder impr ve for pure ec of
ale'
❑ p pe y,amexclusive a M i en dexmmmoism TY. PLUMBING PERMIT FEE FLOOD ZONE
Iuasown the ro n Q APN
cona4 et two Jecl(SIN.]044,Bus' can a0 emraemr's
License Law oesa 1app1 m, owh' pr build or impro athereon,and PERMIT ISSUANCE Y`
whoco[nmm forsuch projeIts it o ice dPit U. [h Convector's ALTER-DRAIN&VENT-
Liecti a Lnw. WATER(EA) FEE SUMMARY
❑ 1. ex pt under$ &P C for this reason OUTSIDE FEES
f BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner - Dat<
WORKMAN Ctl EN ATIOND LA Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
❑ Ihercbya firm that lheveacen ✓e�e of cans Go self-insure,orecertificete of SCHOOL TAX Y N
FIXTURE$ PER TRAP RECEI
Workers'Comp deal. I oracran ylhemof(Sce,380,Lab C.)which PARK ME N _
covers ell empl se's under[his permit. GAS-EA.SYSTEM-IINC.4OUTL S E
PolicyN ^
Company GAS-EA.SYSTEM-OVER 4(BA)' PLANCHEC SIGN FEES
�Jy
❑ Certified on y is hereby Juristic
❑ Cenified on is filed with the ty inspection division. GREASFANDUSTRL WASTE INTERCE - GRADIN
CE TIFICAT F EXEMPTION FROM WORKERS' GREASETRAP S
C PENSATION INSURANCE
(Thissemion d completed ifthe permit is fwone hundred dollars($100)
or less.). SEWER-SANITARY-STORM EA.2WFT. E
Icertify that in the performance of Ne work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any rammer so as m become subject to the Workers' pplp '
Z Compensation Lawsof Califomia, Date WATER SYSTEM/IRFATING ¢ Raeiptk
Applicant
z 0 NOTICE TO APPLICANT:ILafmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
Fbecome subject to the Worker's Compensation provishours of the Labor Code,you must
forthwith comply with such provisions or his permit shall be deemed revoked, BUILDIN FEE 'e
Z CONSTRUCTION LENDING AGENCY SEISMI E, �•
I humbyaffrm that mare I,.em umetion lending agency for the performnnoeof �. ELECTRIC
V O the work for which this permit is issued(Sec.3097,Civ.C.)
{2. I~ Lender's Name
Lender's Address QTY. MEC14ANICALPBRMIT PEE PLUMBING FEE �k
tI certify that 1 have road this application and slate that the above information is MECHANICAL FEE
correct.l agree to comply with a 11 city and county ordinances and state laws relating to PERMIT ISSUANCE
h building construction,and hereby authorim representatives ofthis city toenrw upon the
L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TA
.^� (We)agree to save,indemnify and keep harmless the City of Cupertino against Judi lies, mls,vmt,mdexPmcaiwhic2pmay in my way accrueagainsl said City AIR HANDLING UNIT(TO IgWO CPM)
of the granting of
"J AIR HANDLING UNIT(OVER I0,000 CFM)
Signa of Appl' Withancefilf DA. EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date R tN
Will the applicam or future building occupant store or handle hazardous material,
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00h)(00 BTU) TAL:
Code,Section 25532(x)]
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will thexpplicantorfuwre buildingoccupant uscequipmenmrdevicee whichemil
BOILER-COME LHIP OR 100,000 ITUD - ISSUANCE DA
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the 199
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand thatif the building does not urrently have a teriam,that It Is my responsibility to notify the �Q
occupant of the requirements which most be met prior to issuance of a Certificate of p
Occupancy.
Owner or authorized agent - Date TOTAL: ISSUED BY:
OFFICE