28138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - HUH,DING-ELECTRICAL PERMIT NO. 28130 8 ^0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L VX Il JK �i(
BUILDING PROJECT IIIR.NfIPICATION
BUILDING ADDRRESS, /! ��/� - SANITARY NO. APPLICATION SUBMITTAL DATE
(O (/ 'n UNUM LOT -
2 64eV�
W ERS NAME: ' P NE: C R'S A IC NO:
v,16 7S NC CONTROI,p
RCIII /ENGINEER: LIC NO:r R r 0
CONTACT: PHONE:
QTY. . ECPRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB D�
pyZ Ihembyaffrmthml um6ARCHITE-CTS
tBecomes,provisiow ofC came,
incense
with
pjc)R Section"/0007 of DivisBusiness mJ Profen'ons Code,aced mylicense is in pgNE1S
aVF Full fore and effect
e.
6,1_ Dansjr lLiamm ////`""' UP T0200 AMPS Q a
m=y Data �GCImcConvacror 201-1000 AMPS A50SQ.PT.FLUOR K v E/SQ.
ZOFIL
,z DECLARATION OVER EXMAMPS
Oz 1 understand my plans shell be used as public records.
SIGNS ELECTRICAL
iy7-4 Licensed Professional
yah OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOaU 1 hereby affirm that I eon exempt from the Commences License law for the
Ia13ay following reason(Section 703 L5,Business and Professions Code:An t t T[iMP.MLTER OR Pi
Any ni y of assn y
�'�','I which reyuiresapennito rmrmructnlmpimprove,demolish,or repair any mount. POWER DEVICES 10,
ret}7 priormits issuance,also requires the applicant for such Permit file asigned statement
y�0 thahe is licensed purauant to the provisions ofthe Contractor's License Law(Chapter
� g� 9(commencing with Section 704)(3)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC ��11 VALUAT'ION�
_y or be 131.5 by anytherefrom applicant
and t for the
basis for
subthe alleged
pplicoi to civiny l
of OUTLETS-SWITCHES-FIXTURES //QQ
€4O no S
ection
mthn5 by mydreddantrsrvpermitsubjects the apPlicmatoecivil penahyof / ll//
yy amore than fivehundred dollars(SSW). NEW RP_SIDENTIALELECTR _SQ.FT.
ty ro ❑ Los work.sfthepropeny,arm o,inanyeeswithwed ormb,Sac.cumprnsiness STORIES TYPE GDNS'IRDGHQN
y will domework.Code:
suuc m is mumanot inmicartm ow does a.( (gee.1044,Business
and Profusions Cade:The Contractors License Law does not apply tom owner of
ownenywhob,Waorimpmvuctiimp,anmentsmaointendortselfmthroughhl, OCC.GROUP RISS.UNITS
howemployebulding,imprsuchimpmvoldwi amort yeardconadetcfed the owner-
buweer ,will avetieorimpmproviis hat he diinore t build of completion,the f TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as ownerofthe progeny,nmexdoaively cmmmning wi(b licevedwnnvcumto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
Lieanae Law does not apply to an owner o f pmpmy who tactics or improves thereon,and
who contracts for such projects with aconarars
ctoom licensed puuant to the Contractor's ALTER-DRAIN@VENT-WATER EA
O
I.Icense Law. PEE SUMMARY
❑ 1 nm exempt uakr Sec. ,B @ P C for this reason
BACK FLOW PROTECT.DEVICE O SID
EFERR
SANITARY Y N
Owner Date DRAINS-F10pR,ROOFAREACOND. RECEIPrp
o . ,4 .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby affirm that l have n eeniftcamofecameanto self-insure,ma arifienteof FIXTURES-PER TRAP RECETPfM
fkera Ctno,a mdonlouurmeeuracenifnocopythe (g$�3800,Lab C.)which � PARK ME Y N
covers Policyyllcmp dr ndorsltie xfiYfla 2 ^ �Y GAS-EA.SYSTEM-I INC.4 OUTLETS RECISION
!O �^� BUILDING DIVISION FEES
o any w GAS-EA.SYSTEM-OVER 4(FAT PLANCHECK FEE
Cenifi copy isherebyfurnshed.
CenifW copy is fled witM1 the city inspection division ORFBSIJINDUSTRL WASTE INTERCEPTOR GRADWG FEE
CERTIFICATE OP FXEMPION FROM WORKERS' ORPASETRAP SOILS FEE
COMPENSATION INSURANCE
(This nation need net becompated ifthe permit is foronehundred dollars($109) SEWER-SANITARY-STORM EA.200PT. ENERGY PEE
or less.)
Icenify that in the purfornence.fthe work for which this permit is iuued,IahWl WATER HEATER W/VENT/ELECTR
not employ any perom in may roamer so as to become subject m the Wmkera PAID
Compensation Lawsof Califamia. Data WATERSYSTE-MITREATING Dam Rocein#
ZZ Applicant
0 NOTICE TO APPLICANT:If,Weer making this Cerifcae.f Eman,alon.y a.thaold NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
r+ DO become subject to the Worker's Compensation previsimss of the Labor Code,you must
�. 7 fonbwith comply with such provisions or his pnmit shell be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
2 I hereby affirm that them is a construction leading agency for the performance ofELECTRIC FEE
V O the work for which this permit is issued Sar.3097.Civ.C.) .�
Lenders Name
1'I' Lenders Address QTY. MECHANICAL PERMIT FEF. PLUMBING ME -/
U 1 artily that I have read this application and state that The above information is MECHANICAL FEE
s�" a correct.l agree m comply with all cityand county ordinances and sate laws relatingto PERMIT ISSUANCE OYa
rA buildingeom uction,and hereby authorize represcmmivesofthiscity m enterupon the CONSTRUCfION TAX
U z above-mentioned Property fur inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify en ttp rs the Ciry of Cupeninc against
liebilitiu,judgmema costs and wN mayinany way mtmeegmmm City AIR HANDLING UNIT(TO IO,B00 CFM)
in ouse,crus,offf grant Pe
AIR HANDLING UNIT(OVER 10,"CFM)
Signato of van Dam EXHAUST HOOD(W/DUCT) - PAID
' IAZARD USM IAIS DISCLOSURE
I1P.ATING UNIT(TO 100,0(1(1 BTU) Date Receipt
Will the licaut or fmure building occupant store of handle haardous material HEATING UNIT(OVER IW,000 BTU) TOTAL:
v deeded by
Cupertino Municipal Code,Chapter 9.12.and the Heabh and Safety
ode,Section 25532(ap VENTILATION FAN(SINGLE RESID)
❑
yes ❑No
BOILER-COMP LHP OR 100,000 BTU) ISSUANCE DATE
Will lheapplicramfumm buildingaccupralma equiproentordeviceswhicheadt PA 1
havarduus air contaminant es defined by the Bay Ara Air Quality Management BOILER-COMP(OVER 100,000 BTU) C
Dixtnct? JULes 0 N NEW RESIDENTIAL MECH.-SQ,PT. J/VY .
I have read the hausel materials requirements under Chapter 6.95 of the 5
Celifomia HeOth @ Safety Cade,Sections 25505,25533 and 25534. 1 undersand that V n,t y
Or
ifthcbuildingdoesnotcurrentlyhaveaTenant,thatitismyresponsibilitytonotifythe ear NO
occupant st b
t of the requirements which mum met pnor to issuance of a Certificate of
Occupancy.
Owner or amhudeM eget Dane T ISSUED BY.
- , OFFICE — - -