28242 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHUR.uwG-ELECTRICAL PERMITN028242
. ^ ^ w a�
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 'LJ CyJg •`J L
BUILDING PROJFICT'IDEN'TIF'ICATION
BUILDING ADDRESS: y0y SANITARY NO. APPLICATIONSUBMHTALDATL'
yz7i�vq
UNITN LOT If
N[RS NA PHONE: CONTRACT'OR'S NAME: LIC NO:
SIC CON`TR0L#
• ARCHITEC71fiENGINEEK LOICNO: I ADDRESS: El
PHOOOIt: BUILDING PERMIT INFO
/'/0� QTY. ELECTRIC PERMIT FEE
l'n. ( ECH
7 ' ��� PERMIT ISSUANCE BLDG/ F,L11 PLUMB 1:1
LICCNSEDCONTRACIOR:S CIARATION APPLIANCES-RESIDENTIAL tLJ�
a9z I hereby affion that)um licensed underpravisionsofChapmr9(commencing with TOB DESCRIPTION
ts100 Section 703 ofthe Business and Professious Code,and my license is in PANELS 1 I
Fy-IIyy full farce end effe�t
Lic.p
auz UPT0200AMPS
Liuve Clew —
y 6 H Date Contmcmr 201-1000 AMPS
zOyZ ARCHITF.CT'SDCCIARATION OVERIOOOAMPS SQ.FE FLOOR A $/SQ.FT.
0 z—❑ I understand my plans shall be used as public remods.
�ro
W SIGNS ELECTRICAL
a wwe Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Cp�Op,V I hereby affirm that 1 am exempt from the Cunnomor's License Law for the
tn3tn f; following rmson.(Section 7031.5,Business and Pmfemians Cade:Any city or county TEMP.METER OR POLE INST.
�I which requires o pemtit m comb 1,ol¢r,improve,demolish,ar repair any awewm
W�Y7 to its issuance.also the applicant for such Ito file a signed statement POWER DEVICES
prior requires pp pact gn
tCW a 0 Nat h0 is licensed pursuanuo the) ovisions of the he Ba cm/s License Law(chapter
LLO�. 9 that he is ixemwith t erefro and the Division Sof the Business do Profession Cad O) SWIMMING WITCHES-FIXT /� VALUATIQay_
,may OOL ELECTRIC
nnhmheisexempt therefrom and the basis for the alleged exemption.Any violmion of OUTLETS-SWITCHCS-FIXTURES Joe rY
P Section]0715 by any applicant for a permit subjttu Ne applicartuo a civil penalty of 0 V
Wa nNen five hundred dollars($500).
mot more❑ I,usownerof Nepmpeny,urmyemplayeeswiN wngesusNeinolecompensmion, NEW RESIDENTIAL ELECfR _SQ.M STORIESTYPL+CONSTRUCTION
a willdo Ne work,andtbe structure is not intended or offered formic(Sec.]tW4,Business
and Profess ns Code:The Conwem/s License Law dues not apply to an owner of
property olmlai ldsarimpfnves thereon,andwhodoeivollwork himselfmthmughhis
employees,providedNmstch improvememre
sanot intendedoroffered formic.If,
OCC.GROUP RLS.UNITS
however,the building or improvement is Bald within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
We.).
❑ I,as ownerof Nmem
e property.am exclusively contracting with licensed conrrsm QTY. L ING PERMIT FEE FLOOD ZONE APN
onswct the project(Sec.7044,Business and Professions Code:)The Connor's
License Lawdces nut apply manownerofpmpany whobuihlsorimproves Merton.and PC IT ISSUANCE
who contracts formch projects with acenwctor(s)licensed pursuant mthe Conuacm/e
License taw. L'Ii:R-DRAIN&V WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sea ,B&P C for this..an BACK FLOW PROTECT.DC CC ID
SANITARY Y N
• Owner Dam RECEIPTN
DRAINS-FLOOR,ROOF,A COND,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I herebyaffirm that i have acenilLcicofconsennoself-insum,oracemific of FIXTURES-PER 9'RAP RECEIPT#
Workers'Compensation Insurance or a certified copy thereof, cc.Jg00,Lab which PARK FEE Y N
cxwcn all employee's under this permit. GAS-EA.SYSTEM. INC.4 OUTL RECEIPT'N
Policy p BUILDING DIVISION FEES
Company - GAS
.
) PLANCIECK EE
❑ Certifiedropyie
❑ CniOeJopysheMI
flWfNmiedoVINDUSTRLWASIEINTRCEPT
GRADING FEF.
CERTIFICATEOFE%EMPIO FROMWORKERS' J SETRAP SOILS FEE
COMPENSATION 1 URANCE 11
(Thissectionneednmbecomplttediflhe rmitisforonehun della (S SEWER-SANITARY-STORME ENERGY FEE
or less.)
I certify that la the peffonnance of the wo for which thio ,1 shall TER HEATER W I GTR
not employ any person in any manner so to become sub Werke PAID
Compensation laws of Califomia. Dam WATERS IN of Date Receipt If
t7 O NOTICE'TO APPLICANT:If,after makingthis\ANCY
Exem t IOTA :
p i ,you should NEW RE DE AL PLMB. SQ.FT.
H U) beoomesubjcauothe Worker's Compensationpme Labor Code,you must BUILDING FEE
a ; foMwith comply with such provisions orchis perecmed mvokcd. �
SEISMIC FEE
6. (]
CONSTRUCTION is a comNLENDLVI hs far which N From,is a cuntmction lforNeperformanceof
U Z TOTAL: ELCCfRIC FIiEONe wok for which Nix permit ix issued l9ec.309
Lender's Name
0 F Lender's Addicsa QTY. ECHANICALPERMIT FEE PLUMBING FEE
V I certify shat 1 have mad this application and state that the a information' MECHANICAL FEE
coned l agree to comply with all city and county ordinances and a vlaws relidng to PE H*ISSUANCE
building conswrder.and hereby amhoroe mprearmshves of 1ocay enterupon the CONSTRUCTION TAX
C) 'J' above-mcmioned Property for inspersion purposes. ALTCR OR ADD TO MECH.
a (We)agree m save,indemnify and keep hwMess the City of Cupenio ain't
liabilities,judgments,costs and expenses which may in anyway aceme againstmid try AIR HANDLING UNIT(TO]0,0ft CFM)
igC2111r�pu.A.Z Ih[pf�nrn8 oft Y ewi
`\\\`jL�'yivr /.`INa/ AIR HANDLING UNIT(OVER 10,00()CFM)
Sim.9 kof APPlimzVC.nwcun Data EXHAUST FOOD(W/DUCD PAID
HAZARDOUS MATERIALS DIS OSURE HEATING UNIT(TO 1(1(1,000 BTU) Date Receipt#
Will Neti,licantorfuture building occupant smrt or handle hawdous material HEATING UNIT(OVER 100,1100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cad,Section 25532fUi
❑Y. ❑No VENTILATION FAN(SINGLE RPSI O)
ISSUANCE DATE
Wllltheapplicanmrfuturebuildingaacupasm use equipmentordevirexwhich emit BOILER.COMP(3HPOR 100,000BTIJ)
• haeuNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
1 have read the hazardous materials mquiremenu under Chapter 6.95 of the P A D
Califomia lienith&Safety CWe,Sections 25505,25533 and 25534. 1 undemuud Nm
ifthebuilding e renot currently have omom,an itis my responsibility enotifythe K
O cupam of Ne rtquiremenu which must be met prior m issuance of a Cenilicam of 'Jul v atr' 995
Occupancy.
Owner or authorized agent Data
TOTAL
OFFICE