28191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B IIA:NG-PICK I'RICA], P12KM11'NO.
APPLICATION/PERMIT r1.uMB:NJECTIDHAN:CAL 28191
BUILDING DIVISION H1111.IIIN(:PRO.IHC'I'IUF.NTIRIUA'I'IUN
BUILDIN�j SANITARY NO. APPLICATION SUBMT TIAL DATE
NIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME. LIC NO'.
WC CO ROI.#
ARCHI'I I.CTIENGINEER. LIC NO: ADDRESS: ❑
CONTACT: PHONE: r QTY. F,LECI'RIC PERMIT FEE BUILDING PERMIT INFO
HLDG E1 'Cr PLUMB MECH
PERMIT ISSUANCE 11 ❑
LICFNSEDCORJRACI'OR'S DECLARATION APPLIANCES-RESIDENTIAL
C=Z IM1crebyaRnn lha lure licensed under provisions ofChepmr9(commencingwith JOB 13C.SCRIPTION
ii100 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
W full foccand effect.
<,, Liccwe Class Liao Up 10200 AMPS
v<ti Date Contractor 201-I000 AMPS
7ONZ ARCHITECTS DERA
CLATION OVER 1000 AMPS SQ.17.FLOOR AREA $/SQ.Fr.
I umdcmmnd my pians shell be uuE u.public rtomcb,.
F-to H W SIGNS ELECTRICAL
DovxW PmfanimAI
C d.ei OWNER-BUILDIR DECLARATION SPECIAL CIRCUI"r/MISC.
XOaF 1 hereby affirm that I um exempt from the Contrucmei License Law for the
Wurn 3following reasoo.(Scutlon 7031.5.Business and Professions Code:Any city or county TEMP.MUER OR POLE INS'I'.
I_u.ON< which requires a permit to construct.alter.improve.demolish.or mpurany froom
f;!IY5 prior br its ixsuunce. Is,,requires the applicant rn"mch petmiun rile a signed staemem POWER DEVICES
�O that he is licensed punuunuo the provisions oflha Contractor's License Low(Chupter
9(ammco,lig with Set, n70W)o1'1)ivi_si..n3of the Bvines,end Pmfes,imlx Gyle) SWIMM ING 11001,ELECT R IC VALUATION
A_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
FZ¢ Section 7031.5 by any applicant fur a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-
FIXTURES
or mom than five hundred dollars(SNOU,
uMu1L:n ❑ I,uxownerofthepmpeny,ormyempinyeowith wagesaslheirsolecompcmmtum, NEW RESIDENTIAL F1ECfR SQ.II'. S'PORIES TYPECONSTRUCI'ION
y3ere will do the work,and he structure is not in¢ndedo,.Ifered forxile(Sec.7044,dullness
and Poll",ions Coda:'rho Contmctors License Law does our apply to un owner of
property who milds or improves thereon,and who does such work himself ser through his
own employees,provided thatsuchimprovememsart not immadadoro(fend forsale.If, OCC.GROUP RFS.UNITS
however,the buildingor improvement is sold within one year ofcompletion,the owner- TOl'AL:
builder will have the burden of proving that he did not build or improve for purpose of
arc).
❑ I,axowncrof dm pmpvrry,umnduelvdy«mtrmlingwith llccnscd convucmmm QTY' PLUMBING PERMIT FEE FI ODD ZONIi APN
Drown the project(Sec.7014.Business and Professions Care)The Contracroh PERMIT ISSUANCE
License Law Joey nm apply m m owne r o f pmlc ny who bu i Ids or im pmvea rM1emm,and
who emaracts for such projects with a eonuacmr(s)licensed pummin to the Contractor's
License law. ALTER-DRAIN A VENT-WA-1'IR(EA) FEE SUMMARY
❑ I am excnSa under Sac. ,B R P C for This reason OF,11STIDE FEES
BACK .OW I'RO'115CT.DEVICE SANI'T'ARY
FLOW N
Owner Dom RECE119'#
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ thereby a(fim6 that l have a cenifica¢ofcunsent to self-insure.or a certificate of PIXTURF_S- RF.CETPT#
lie Workers'Compensation Insurance or a rectified co 0emof Sce.3800,Lab C. which PER TRAP PARK ITE Y N
�nxamm� copy ( )
"we
null employee's under this permit. GAS-EA.SYSI EM-I INC. OF I'LFTS RECEIPT#
Policy# BUILDING DIVISION FEES
Cumpuny GAS-EA.SYSTEM-OVER 4(EA) PLANCHI CK FF£
❑ Centra copy is hereby famished.
❑ CenifiM copy,is file with the city impaction division. GREASEIINDUSTRL WAS1EINrERCEPOR GRADING FEE
CFRTIFICATG OF EXEMPT FROM WOkKliks' Er]RAP SOILS FEE
COMPENSATION INSURANCE?
(INs section need not he completed;fire permit is for" hundred doll I SEWER-SANITARY-STOR ,A.20�F1'. ENERGY FEE
or less.)
I ccnify that in the performance of the work which t pe is's ed,lshdl WATER HFA WN iLE R
not employ any"an in any manner n as m become Ire IM1e Wortcrs' Pg1U
Compcnxntinn lows of CuliGrmm. Dams W YSTF.M RFXTIN1 ale R -rpt#
.Z Applicant
z 0 NOTICE;TO APPLICANT:If,vfmr muting this Cenificat.uer ptiom.youshou NEW R NTIAI.PLMB. SQ.Fr. AI:
ry bccan¢mbjecuo the Worker Compensation Provisions oftheVborCWc,you mu
forthwith comply with such provisions mills permit shall lc deemed revoked. BUILDING
Rwi Q CONSI'RUCTION LENDING AGENCY SEISMIC I97E;
7 Z Ihereby affirm that them is u construction lending agency for the perforiance of
V O the work for which this petit is issuN(Sec.3NO.Civ.C.) TOTAL: ELECTRIC FEE
lender's Name PLUMBING FF
Q U lender's Address - QTY. MSCI IANICAL PERMIT FEE
1 unify that 1 have and this application and state that the above information is
�" correct. la r t Imam Minuneexand sere laws minim�m PERMIT ISSUANCE MECIIANI LFEE
grccm annpy a�yant yo g
budding comouclum.u crcnya ori m representatives of his city to enter upon the corvs UCfION TAX
O 'z aboff1c
ny(afire tion purposes. ALTER OR ADD TO MECH.
(We) ,in!A mi erb tap harmlcsa IM1e City of Cupactino agairm
b.bnsande awhicM1 rosy many way acemeagainxmaiJ Ciry AIR HANDLING UNIT(TO 10,11(10 CFM)
in vnin 'Thu pcnnit.
AIR HANDLING UNIT(OVER 10.000 CFM)
gnatu a OContraor ate 17XIIAUST HOOD(W/DUCI) PAID
H ]ARDaDO
MATERIALS DISCLOSURE - HEATING UNIT(TO 100,000 BTU) Date Receipt#
Willi cupplicu I or future building occupant store or handle hvmdnox material HEATING 11N1'f['(OVER IW,IXIO BTU) TO'1'AV.
as 1i IbcC ,rfoo Municipal Calc,Clwpter 9.12,and the Hcallb:md Safe,,
C Teel El No 32mH VENTILATION FAN(SINGLE RESID)
❑
Will tBOILER-COMP(3HP OR 10(1,000 BTU) ^ (,�/.SSI)SCE DATE
he applicminrfuturt buildingoccupam uucquipmem ordevicc,which emit r
bacur oux air emounitrams as defined by he Bay Area Air Quali y Management HOT LER-COMP(OVER IW 014)H'rU)
Dlstrint
` ❑Yet, ❑No NEW RESIDENTIAL hfECf1. SV.14. 'JUN 19 9995
1 have rtW the mumlom materials requirements undh Chapter 6.95 of the /sT�5] L T
California Health R Safety Code.Sections 25505,25533 and 25534. I undersand shat V�11 Uri VUYEHI�NO
if the building doe,mol eurcnmo
dy have a len,tat hit is my responsibility to notify the
occupant of the rrqulrcmc7us which must he met prior m i,xwmcc of a Certitwalu of
Occupancy.
Owner or umbmmed agent Date TOTAL: ISSUED BY;
OFFICE