28362 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILV:NG-ELECTRICAL PERMIT NO. aww ��
'LJ
BUILDING DIVISION APPLICATION/PERMIT PLUMB NO-MECHANICAL
BUILDING PROJECT IDENTIFICATION L yC(7
BU DING ADDRESS: - SANITARYNO. APPLICATONSUBMITTALDATE
O UNIT# 1.03'#
OWNERS NAME: PHONE: CO LT R'S NA Ga LICNO: N/C CONTR L#
IftrRCU :L /ENGINEER: LIC NO: A ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
.D ELECT PLUMB MUCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hemb ffna Nm l am licensed under rovisionsdfCh t r9 commencin with LOB DESCRIPTION
C]L'Z Ya P and ( 6.
0W0C SenioalmilE fDivision]of eBusiness add Professions Cade.and my littnx is in PANELS
V U fall farce and e-ect. I/r ti ll s/1'1 G
PQ„ZLLI License Class Lisp_ / /dd(/� UPT02MAMPS
mQa Dme ontmcon �6 2111-TWO AMPS
F'O" ARCHITECTS DECLARATION SQ.FT.FLOOR AREA E/SQ.FT.
OOm 1 understand my plans shall he used as public records. OVE0.1000 AMPS
4Z SIGNS ELECTRICAL
Licensed Professional
�,a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a�4O y V I hereby xffind that I ore exempt from the Contractor's License Law for the
W 3"u,a following remand.(Section 70313,Business and Profession Code:My city or county TEMP.METER OR PULE INST.
BOJ which require,a penah meonswcl,alteq improve,demolish,m oticirmyswctire
` ;!I'j prior.is iesuame,alsam thea licant for inch .it fileasi dad statement POWER DEVICES
"�a t t quimm to m pP pract 6
QO 9(corn encensod Pursction7he)ofDiaosof the Contractors andLicPronam Low(Chapter
SWIMMING POOL ELECTRIC' VALUATION
>.ao� or don heI.
Section7")ofbisisi�n Sof Ne edeBus.e.piti Professions Cade)
�Zy
ordon703exempttyapplimand the Permit
rthects thedesemant to civil
of
�ZG Section by any applicant fora permit subjects the applicommarnil penehy of OUTLETS-SWITCHES-FIXTURES
not come than Eve hundred dollars(5500).
❑ I,mowneroftheproperty,ormyemployeeswithwagessstbeirsolecompemation, NEW RESIDEMIAL[LECTR _$Q.PT. STORIES TYPO CONSTRUCTION
L will do the work,endthesmacmre is not inanboloroffeted for sale(Sec.9044,Business
and Professions Code:The Contractors License Law does dol apply to an owneof
property w ho bo ilds m improves thereon,and who does such work h i msel f or through his
OCC.GROUP RES.UNITS
wn em pluyees,provi dad that such improvements are not)nteMod or offend for salt.If,
however,the
avet a urimprovement is soldedidnot year ofcomove far thrower- TOTAL
builder will have the burden of proving Nm he did not build or improve fm purpose of
ale.).
❑ I,as owmraftheproperty,mnexdusivelycommaing with licensedcontractors o Qom' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Connector's PERMIT ISSUANCE
License law docs not apply to an owner ofproperty,who builds or improves thereon,and
who commas far such projatswithacontrinums)licensed pursoutm nCadtrxmrs ALTER-DRAIN ENT-WATER FEE SUMMARY
License Law.
❑ I am exempt under Sec. ,B&P C for this reason BACK FLO ROTECf.DEVICE OUTSIDE
SANITARY Y N
Owner Date DRAT -FLOOR.RODE,AREA,COND. RECEII'f#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihenby affirm thin lhaveattnificate ofcmtmmmself-Insure,macmifcate of URES-PER TRAP RECEIPT#
Woakni CompcnsutionlnsurancenracenifNcopy thereof(Sec.3800,Lab C.)which PARK FEE YN
en all employees nada this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RECF,IPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVIM 4 EA) PLANCHECK FEE
[2 Centuries]copy ishemby famished.
❑ CertifiW copy is fled with the city inspationdivisian. GREASEONDUSTR.WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP sk rA SOILS FEE
COMPENSATION INSURANCE
(This section dad not becompletad ifthe permit is forom hundred dollen(EIOE SEWER-SA ITA RM EA.20044"") ENERGY FEE
or less.)
I ttnify that in the performance of the work for which this pandit is issued,Isbell E L
not employ any person in any manna so m an become subject to the Workers' PAID
Ciannumsumnlawauf Celifnaia. Date- -"q SYS TJRr Date Receipt#
Z Applicant
E SIDENTTAL PLMB. SQ.PT.
Z Z NOlicant APPLICANT:If,afar making this Certifier¢o(Exemption,you should
(q become subject to the Worker's Compensatian provisions ofthe Labor Code,you must BUILDING ME
comply with such provisions or this Permit shall be deemed invoked.
IS] Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm priu in is construction lending agency for the performance of
V O the work for which this 1,permit is issued(Sea 3091,Civ.CJ - TOTAL: ELECTRIC FEE
If. Lenders NamePLUMBING PER
Leader's Address QTY. ANICAL PERMIT FEE
V 1 cerify that 1 have mama this application and amts that the above information is MECHANICALFEE
>^ 4 cooter lagreemcomply with all city and coumy ordinances and state laws relating to PERMIT ISSUANCE
V N building construction,and hereby authorize reprexmatives ofthis city toemer upon the CONSTRUCTION TAX
above-mentioned property our inspection purposes. ALTER OR ADD TO MECH.
(We)office to save,indemnify and kap handers the City of Cupertino against
Iiabilimiw,judgmenms,casts and expenses which duty in my way accrue against said CityAIR HANDLING UNIT(TO IO.OW CFM)
in<.sequence the granting of this it.
AIR HANDLING UNIT(OVER 10,(X10 CFM)
eyo
ilimureof Applicant/Contractor Dale-117L7 EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1100,0100 BTU) Data Receipt
Will the applicant or future building occupant store or handle hazardous materialIPSyk
HEATING UNIT(OVER l OQ000 BTU)
as defneE by the Cupertino Municipal Chia Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION PAN(SINGLE.RMID)
❑Yes 11No f.�GTE VWill theepplicanmr(utumbuildingcecupantuseequipmemordevicemwhichemilBOILER-COMPLUIPOR1(10,000BTU) 0
hixatdmu air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Diskt? 13 yea ❑NaJUL 11 1995
NGW RESIDENTIAL MECH.-SQ.FT.
1 have read the hazardous materials no uinments under Chapter 6.95 of the
California Hea1N&Safety Cade,Sections 25505,25533 and 25534. 1 understand that CITY Ur ULMh I I I
if the building does not ctren0y have a tenant,that it is my responsibility to minty the
occupant of the regair mems which most be met Our te issuance of n Certificate of
Occupancy.
Owner or authodmil agent Date TOTAL: ISSUED BY:
OFFICE