28096APPLICANT TO RLL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECFRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL96
BUILDING DIVISION BUILDING PRIIJECT IDENTIFICATION
, w 0
PERMIT NO•Lf
FjRLD[NO ADDRESS:
W UNO'x LOT♦
SANITARYNO.
APPrIICATIIONSUBMIITALDATE
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O #ERS NAME / k% -z. No 1 /e11PIIONG
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C MRA R'S NA B: ^_ � � LIC NO,
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COIII.�OL 0
ARCHTHiCT/FNGINEFR: LI NO:
ADDRFSS:
COW AM: PHONE
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE?
❑
LICENSED CONTRACTOR'S DECLARATION
IFc")oRrmthiol amli<cmHuai. poviniansofCTCpe.9arai mr,Uc ere is lt
7")ofdo Nmira and Pmfnuora Code..rd my Banuuin
in
APPLIANCES -RFSIDFN'1'IAL
DESCRIPDON
PANELS
follfi
full home u.d eRm
L4vue Clu+ tic. N
UP TO 200 AMPS
1 _
Date Cosmoctur
201. 1" AMPS
ARCHFECFS DECLARATION
1 undcrstaM rr plans hail Ic uaN m public records.
OVER I(p0AMP5
SQ. IT. FLOOR AREA Sao 'PT.
SIGNS F.LF.CTRICAL
Liccnw.d Pmfminnel
OWNER -BUILDER DECLARATION
SPECIAL CIRCUMMISC.
I wrelny affimt that 1 con exempt from the CnmrmTm's License law for the
TEMP. METER OR POLE INST.
following macron, (Section 7031 L Buunns and Irmficrusaas Code: My city car county
winch rpluims., p omit m,.uuc,, alter, imprnvc, dconoish, or repair y.l ,om
prim to iu i.vuna,also "ubaathe Hylicnmfor auch pernut to Be a signedstatement
POWER DEVICES
that w u Iicavnd llorrou to the povi.sioncof tM Cmuvatc'I U. Law (Chaper
9(comnencing with Section 7")of Division 3a(the, Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he its exnnN tbcrtfrom and the nmir for the alleged exemption. Any violation of
Section 7831-5 by any eppliesm Tetapecua.ubjecry the applicant toss civil penal tr
OU S - SWITCHES - FlXTIJRES
um more to. Eve hmdred dullms ($SW).
❑ I,mowrtnofthel*4SrtltarmyempbymwiNwagesvtheirwle<mnpcovNnn.
NEW RPSIDFMIAL ELECER SQ. FT.
STORIES
TYPE CONSTRUCTION
will do tic wM, aN tw 4meturt i. m inteand moffeml for sale (Sec.70f . Bm noon%
and Profeaioas Code: The, Cmmnar s license law doe not apply to an omit M
pmpeny who build. orimpove, Iherton.andwMdxisuchv,ark ldnuelfu Wnwgh his
wn empbya+, povalN unit ouch impmvencnu are ria Intaalcd m Mfeied fa ado. If,
C. GROl1P
RIS. UNITS
�
wwe.er, the wilding m impmvemcm in,de wlNln one yema eaopletion, meewrter.
badder win nave the budU n(pmving tM1u h<die cot wild m Improve fou pupme M
Qom' PLUMBING PERMIT FEE
sale.).
❑ I,umvnaofthc lxgcnY.rem ecluaivelyconuvctingwitM1 lianxdcmtmnmsto
FLOOD?,ONE
APN
urtutrucl tow Itr,yct (Sea. 7(F4, Boom. and Pmmo,om Code:) Tha Conlmna's
PERMIT ISSUANCE:
Ijmuelawdcxa,..pplyt. an ownnofprupmywwwildt to improve. thereon. anal
wwcommca frrsucM1 p,'et,with. cormoscoar(a) licrnvd partum to the Cawaclah
acme law.
AL'IPA-DRAINA VENT
FEE SUMMARY
❑ E wn crump uraln Sa. , B A P C fm thu revut
BACK FLOW PROTECT. DEVICE
OUTSIDE FES
SANITARY Y N
RECEIPT#
Owrcr Dae
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION UECIARATON
SCI IDOL TAX Y -N-
WMm'Campensaion lnlumna mecrnihed copy thertaf (Sa.JtltM), Leh C.7 wlncM1
RECEIPTx
-RECEIPT -
PARK FEE Y N
err all cmpbyee's tuber Nu permit
Polios 0
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT M
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK TEF,
[Icoo,secry copy isM1nchy fumiJoW.
GRFASEJINDUSTRL WASTE INTERCEPTOR
GRADING
❑ Canifee copy is filed with do city impaction division
CERTIIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 21gFT.
ENERGY FRE
(ITU a a tion reed uotbcromplmN ifthepmnit efamchtmGad dolWa(SI WI
or Ems.)
WATER HEATER WfV /ELECTR
I certify that in th<perfomarce of the wort for which tTupdrnit is Wood!. l dull
so
rat employ any p un in any ret as to bconc .ruhjco to the Wtxkrn'
1
WATER SYSTCAVfREATNG
Compemttionlawaef. Calif. Date
Dae Race x
Applica
NOTICE: TO APPLICANT: If. after mating unit Cerd6aaw of l?xempion, you should
NEW RESIDENTIAL PLMB.
TOTAL:
hccens, mInjal to the Worker's Gonpemation ptovisimst of the labor Cade, you must
BUILDING FPL
forthwith comply with Inch povisiom or thio pem k dull be Axncd meted.
CONSTRUCTION LFNDLNG AGENCY
SEISMIC
SEISMIC FEE
FEE
I toothy affirm that is a connrunimt lending.geney fm the pMomurce, of
do wok fm which Oda permit issued (See. 31197, Civ. CJ
TIYTAL:
LMn's Nmoa
Lao .Address
QTY. MECHANICAL PERMI FEE
PLUMBING II
1 certify that I move read tri. a ylic,tion and nate that the above inftarmalort is
cvnm. Iagma to comply with Al city and county not afd sate 1. relating to
PERMIT ISSUANCE
MECIIA
wilding consuunioo, ami herebyemhorire rtparenmive of Nia city to amer upon Use
above-nnentioned Iaropery for inrycetim puryosn.
ALTER OR ADD TO MECU.
CONSIR ON AX
(Wc) agree to save, indemnify not keep wrmlem the City of Cupertino agaiw
liabilitin,juegnren mu and expeme which may in any way occrue againstsaie City
inc mra,umnreor lingofmj�P� L
T �S:1151'Ai'�. ke-u� V/I acl
AIR HANDLING UNIT (70 1 A000 CFM)
AIR HANDLING UNIT (OVER 10,00tI CFM)
Slgvtureaf ApplieadoCeanmme Due
EXHAUST HOOD OVID=
PAID
HEATNG UNIT CTO IM." BTU)
IL RDOUS MATERIALS DISCLOSURE
Dm Receipt #
Will thcapplitnntor future wildutgocoo,ont.tme or handle baundom material
m dcfnal by the Cupxtlro Momici a] Cradle, Chaps 9.12, analuhc HUM.nd Safety
((EATING UNIT (OVER 100,000 BTU)
VENDIATION PAN (SINGLE RPSID)
Cade, Section25332(.)?
0 Yea 11 No
Will theappliUmmfuturt wilding acupant use equipnmt mecice which emit
BOILER- COMP DHPOR 100,000 BTU)
e_A IS E))ATE
J�
ha� ?, air ocrommiwnu m eefnM by 0u Bay Area M Quality Muta,,er t
BOILER - COMP(OVER 1M." BTU)
/ ry
y1,, ww d V
❑ Ya ❑ No
�`^ ��
NEW RESIDENTIAL ME". SQ. FT.
1 have read tic M1aeaohmu materials u,uimtem, under Chapin 6.93 of the
Califomi. Hmlth & Safety Code, Saoionn 23505, 25533 and 255M. I nMnrtaoJ hal
`LN 995
C,S.
If the building doe not currently have a term, Wer it u my rtapondbiliry to notify du
actopam of the resryirencnu whuch must M met poor a irma.'a of a Cmi fimu of
/AO
,, II
Occuporcy.
.
ISSUED BY:
OvtcrawtMrizN sem Dae
TOTAL:
OFFICE