28019APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPESION APPLICATION/PERMIT PLG, PROD CT IDENTICAL
BUILDING DIVISION pU11.U1N0 PROJECT IDENTIFICATION
PIRMIT"° 28019
BUILDING ADDRPSS:
SANITARY NO.
APPLICATION SUBMDTALDATE
/l2 UNIT# LOT#
E AME'adqCAAj I PHON
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2
CONTRACTOR'S NAME: LIC NO'.
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NIC
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CHITIiCUENGINFlR: LIC NO:
ADD ESS.
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CONTACT': PHONE:
'x>` '* "- , ,
QTY-` ELECTRIC PERMIT.' .. FEE
BUILDING PERMIT INFO
BLDG LECT PLUMB MECH
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tee c
vF �'...k,•.:'n.+A'4:.: s.«: Y. ..
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby aff rm 1 hat I am licensed under provisions of Chapter 9 (commencing with
APPLIANCES -RESIDENTIAL
1 pDESCRIPION
PANELS
UPT0200 AMPS
Section 1000) of Division 3 ofthe Business and Professions Code, and my liana is in
fu 11 force and IT I •7
Data Canwcsm y
Licenu ZI - S` Lic.#�
ARCIIITECTS DECLARATI
1 understand my plans shall h used as public reconfs.
Aw
- 1000 AMPS
OVER
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. PI'.
SIGNS ELECTRICAL
License) Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm Nm 1 um exempts from the Co License Lew for the
TEMP. METER OR POLE MST.
lions Cs
fallowing mason. (Senion "1031.5, Rofwsiona Code: Any city recount,
aft e,
t, improve, repair any torment
which its is a permit ro toms the alley improve, demolish, file awlemcnt
its throvisinsapplicant f ch
suntto
POWERDEVICES
thin he pursuantthe the CopemdssoLicese La
9 (c he is licensed p Sectio m she provisions of the Comrmmr's License Law (Chapter
9(commencing with Section T00(1)ofDivision J of the Business and Pro(easians Cade)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom end me basis for N<alleged exemption. Any violation of
Section 7031.5bymyapplicant for a permit subjects the applicant too civil penWty.f
OUTLETS -SWITCHES -FIXTURES
not m1,eowIn. fiofthepoperrydollars
mycm).
❑ Les rondthespcny,arm
NEWRESIDENTIALELECIR_SQ.FT.
STORIES
TYPE CONSTRUCTION
not Intendede a
will doth Wolk, and of imendedorohwegeed nvalsirsolecompBusines
TBi4.owner
of
end Professions Code: The Contrmtors License Lew dos not apply m an owner of
e: The Com w does not apply
property who Mills,Timpmvciflismon,ind whadaamchwork himselforthrougbhis
own employees, pmvided that such improvements art not intended oraffercd f n sale. If.
DEC. GROUP
RES. UNIT'S
.
hnwevcr, the buildingor improvement is sold within one yearef completion, One owner-
builder will have the burden of proving that he did not build or improve for purpose of
Q�Y' INLUMBING PER MIT FEE
sale.).
❑ Lusownerofshepmpay,amexclusivelyconttactingwiNiicensedconuact.l.
FLOOD ZO
APN
construct the project (Sec. 7014, Business and professions Code;) The Comment's
Liana Lawdasnot apply manownerofpropeny whobuildsor improves themon,and
PERMIT ISSUANCE
who conhmnfor such projects with a contractor(a) licensed pursuant to me Contractors
License Law.
ALTER (EA)
K
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for Nis numn
BACK FLOW PROTECT. DEVICE
OUTSIDE
Y Y N
RECLIPTp
Owner - Date
DRAINS - FLOOR,ROOF, AREA.
WORKMAN COMPENSATION DECLARATION
' ❑ Iherebyaffinst Nn l have o anifcme ofcanum to self -insure, or certificate of
Work. Carl ... ion lnsumnceoraoenified copy thereof(Sce.3800, LMC.) which
covers all employee's under, this permit.
Policy#
H Y N
RECEIPfp
FI%TURES - PER TRAP
PARK FEE Y N
RECEIPT' #
GAS - EA. SYSTEM -1 INC. OUTLETS
BU . DTV 10 .E
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHT:CK ME
❑ Certified copy is hereby furromed.
GREASE/INDUSTRL WASTE R_CEMR
GRADING FEE
❑ Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP v`t,L
SOILS FEE
COMPENSATION INSURANCE
SANITARY -STORM EA.3ftK,
ENERGY FEE
(This section need nosh completed if Ne permit is foroae hundred dollars ($I(0)SEWER-
or less.)
I certify that in performances, perfornofthe work for wid th itnomad Isbell
WATER HEATER W/VENTIF.LF.CIR
not employ any person in my manner sm m h �1 Lib' a hrWcoloc.'
Cnmpenmtio faf Cr#Is(omlo am
PAID
Data Receipt#
.w
WATER SYSTEM/IRI.ATING s
Appli<
NOTICETOAPPLICANT: If. after making th' nifaw of Exemption, ya sould
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workcra Compensation provisions of the I<hr Code, you must
forthwith comply with such provisions m Nis permit shall Inc, domed revoked.
flU G FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby amort don them is a construction lending agency for the Performance of
the work fm h whicthis permit Ts lame (Sec. ID99, Civ. C.)
TOTAL:
ELECTRIC FEC
"'-
MECHANICAL '��'MECHANICAL PERMIT FEE
PLUMBING FEEani
Lenders Name
Lewers Add..
I fy that 1 have read th appli tion and some that We above information is
corms. I ague to comply with all city and county ordinances and slow laws mining to
PERMIT ISSUANCE
MECFIANICAI. HE
buildingcomouction, mdbereby aathadre uprcacntmives ofshis city toenter upon the
above-memioned property for inspection Popes..
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
HANDLING UNIT (TO 10,(100 CFM)
(We) agree to save, indemnify and keep hvmleas the City of Cupertino against
liabilities, judgmeots,cats and expenses which may in my way accom.gainnsaid CityAIR
AIR HANDLING UNIT (OVER 10,0011 CFM)
I. consequence of the g.dn, of this permit.
EXHAUST HOOD(W/DUCD
PAID
Sigmtuof Applicant/Cont.t.1 Daw
ro
HEATING UNIT (TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dale Receipt#
HEATING UNIT (OVER 1W," BTU)
Willthcapplicrosorname building occupantsareor handle hoaardaus matenal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safes,
VENTLATION FAN (SINGLE RFSID)
Code, Section 255R(e);
Yes ./
❑ /gyp.—
.– ISSUANCE DATE
Will Weupplicanlnrfumrtbuildingacupumuse equipmemardeviceswM1ichemit
BOILER - COMP CHIP OR 100,000 BTU)
w.ca"tous air contaminants as defined by the Bay Area Air Quality Management
BOILER - COMP (OVER 100,003 RTU)
issrics? ❑ Yes / \\� JJq0.tlp—
MAY 15 1995
NEW RESIDENTIAL MECH. SQ. P7,
1 have read the haemious materials rolummens under Chapter 6.95 of the
California Health&Safety Coda, Sections 25505, M533 and 25534, 1anchoomd that
CITY �r GurEFfil )
L
if the building does not currently have a mnany that it is my responsibility to notify the
__�— �-
occupant of the min iremerns which muss be met poor to issuance of a Certificate of
_
Occu a
ISSUED BY:
Owururauthen en ate
TOTAL:
OFFICE