28364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMIT N028364
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APPLICATION/PERMIT I'LUHBIN'G-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT PENT]FICA']
BUILDING ADDRESS: n {f'1� SANITARY NO. APPLICATION SUBMITTAL[)AT O /�"PJ UNIT# LOT 115
OWII'1'�t' A /N �y yI�ws CONIRAC9Y)R:S NAME. 11 t '1l
(i YV.A�i��`I�YT NIC CON'IROLN
ARCHITECOEgGINEER: LIC NO: ADD CSS:ft— Elq , l
J CONTACT', PHONE.
Q'fY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
l PERMIT ISSUANCE
LICENSED COM'NACTOR ndc,,mSion,ofDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Detz00 II7"dounion lIsm n 3 ofthensed Husimesand rofesiosCode,and
memein,my
with
WOO fullf..cc")ofDlvlann3af the Rosiness and Professions Cale,acid my license ix in PANELS
FKUU full fnrtt mW e((ttt. 1 �� I(l
<,, Liennsc Clary Lic.0 UP T02W AMPS
v<c_ Date Contractor 201-IKK AAI PS
7OyZ ARCIIII'EC'1'S DECLARATION OVER IIXXIAMI'S SQ.IaT.FLOOR AREA 5/SQ.in.
O Z_O 1 understand my plana shall h used as public records.
SIGNS ELECTRICAL
Q 7,4 Licensed Pmfessiooal
�'ti OWNER-BUtLDHR DECLARATION SPECIAL CIRCUIT/MISC.
tXyO W U 1 hereby affirm that I nm exempt pont the Cnnlracun's License Law bur Lha
R+�+R-tn following muton.(Nation 9031.5.Business and Professions Cada:Any city mcaumy THMP.METER OR POLE INS 1.
FSC; which requires a permit 10 consumer,alter,improve,demolish.or repair any svumum
n
,W}7 priooitsissuance.also"arms the applicant for such Permittoriileasignedstatement POWER DEVICES
4W C) IM1m he is licensed from t to the provisions of the Contractor's License Law(CTaptcr
e.yoa 9(commencing with Section 9000)uf Division 3ofthe Bmincsmnd Professions Code) SWIMMING POOL ELECT RIC VALUATION
W vi or that he is excmpt lM1erefrom and the basis for the alleged exemption.Any violation of
FZQ Section 703 IS by any applicant for a permit subjects the applicant m a civil penalty of OUTLETS-SWITCHES-FIXTURES
ASO
std....him five hundred dolWrr(55011). NEW RESIDENTIAL ELECIR SQ.FT.
K pm ❑ Luuwnk,odep,em,nnrmot iminyedorofwed for sale
campenemiox- STORIES TYPE CONSTRUCTION
y3— will P ata work,CJVt The Contractors
intendede offered does.,It
apply
1o44,esner If
and erty,who
obu Codr improves
ves flu econ,License coca
doer oat apply to an rough of
property,who builds or imph at suchemm.and who dors such work M1imalf or through his
own employxs,pmviJNmprovemenpis sold within
not earmeadoroffemd for then sale.If. OCC.GROUP RFS.UNITS
buwevegthe building uden of osinixhathedidnoneyear ofcompletion,turposer-
bale.). will have the burden of praying that he did not build or improve for purpose of
sole.).
❑ I,as owner nl'Ibe Property,AM exclusively contracting with licensed conlrednn to QT)?' PLUMBING PERMIT PEE FLOOD ZONE APN
construct the pmjmt(Sec.]014.Business and Professions Cede:)The Contractor'.
License lawdoesm apply to an ownerofproperty,who buildsor improves thereon,and PERMIT ISSUANCE
who vontmms for such pmjectx with acnntractorT.$)licensed punuum to the Contractors
License Low. AI:TER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um excmpt under See ,B&1'C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dam DRAINS-BOOR, r ARIiA,COND. RI!CT!TPfN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ 1herehysifon lien l have accnifcme ofemxsenuo self-inaum,nrattrlife:ire of I'IX'fDRE$ :H TRAP RECIeIPrk
Wnrken'Cnmpuuatinn lo,contee ant cenifed copyfletcaf(Stt.3800,Lab C.)which PARK FEE Y N
covers all employees under this permit' G -LA.SYSTEM-1 INC.40 LETS RECEIPT N
Policy N BUILDING DIVISION R31S
Company GAS-EA.SYSTE -OVER4(EA) PLANCHECK FEET
❑ Crimped copy iv hereby famished.
❑ Ceni&d copy ie Tiled with the city inspection division. r�-oddl..($1Ny
GRFASFJINUUSTRLWASTEINfER ',P10R GRADING FEE I
CERTIFICATEPE EXEMPTION RAN WORKGREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(Ifiis section need notMcompleteJ if Oepermit is far one huSEWER-SAN RT-STONM EA.2IIPI IiNERGY FEEcssJI rectify that inose performnce althe work fire which this lK WAT I /VENT .not employ any Mtson in any manner as to tecoma mbjPAID
Z Compensationlawxaf Cilifomia. Dae so YSIC 'JIHG Doc RttciplN
Applicant
O O NOTICE'TO APPLICANT:IL a0crmaking this Ceni fate of mmExctn not,You shni NIiW iS1Uli A MB. SQ.
beronbjen to the Wmkers Compensation provisions of me L:tW Cade.you
forth%no comply with such pmvisiora or this Permit&hallthe,deente voted. BUILDING ME
G Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
'J Z Ihereby.fins that thcte is a wnevunim,lcndingagcncy fir the crfI'manceof
U O the work fur which this permit ix Issued(See.JIN],Civ.CJ 'DOTAL: ELECTRIC FEESaw
lender.Name PLUMBING FEE
Lenders Address QTY. GHANICAL PERMIT FEE
U 1 ccnify that I have read This application and some That the all in onaeon is
correct. I agree to comply with all city and county ordinances snd,nue laws latingm I'13 'ISSUANCE MECHANICAL.THE
F' (� building construction,and hereby authorize representatives of this city to enter nn the CONSTRUCTION TAX
U Z above.mentionedp upery for inspection purposes. ALTF,RORADD TO MECH.
(We)Dorm to save,indemnify and keep hornless the City of Cupertino aguim
liabTiiics.judgmems,cmtx and-tomaea which may Iran,way c enga1. smdCity AIR HANDLING UNIT TO I g00o CFM)
in onxequefib :ani %(This emit.
AIR HANDLING UNIT(OVER 14000 CPM)
Proton,a Appliam(Cminuetor Doc EXHAUST FOOD OVIDUCT)
PAID
I IAZARDOUSMA'TERIALS DISCLOSURE, HEATING UNIT(TO IW,O(X)BTU) Date Nrecin#
Will the applicant or future building occupant slum,or handle roardoua material HEATING UNIT(OVER 100.0)(R)BTU) TA .
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Eleallh and Safety
Coda,Section2553200?Yes ❑No
x)?
❑ VENTILATION FAN(SINGLE RESI))
Yes
Will tM1eapplicim or Tatum hnilAing«apanmsecyuipmem nnlevimewhich emit
BOILER-COMP CHP OR 100,001)BTI]) ISSUANCE DATE
1 �Illdhs air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER Half BTU) P A a
❑Tex 11 No NEW RESIDENTIAL MECH. SQ,Fr.
I have rad the hueanlous Inmerials myaimmenb under Chapter 6.95 of the JUL 11 1995
California Health&Safety Cotx
Code,Sections 25505.25539 and 25534. 1 underend That
if the building tlms not currently have a tenant,that it is my responsibility to notify the 1
Occupancy.
occupant offlue requirements prer m
uireents which must he mel iissuance of•Cenifieate of
CI I Y Ur INUIT`. l I
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE