28235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO It ILDUSU"KLEC'I'RICAL PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL O O C
BUILDING DIVISION BUILDING.PROJECTIDENTIFICA' JON o JJ
BUILUIryGA UR � NITp Lt"I SANITARY NO. APPLI TION SUdMITI'AL DATE
1Lrbu t110 DT# `J 6 ' 1-117
OW A :: PHONE: ACTOR'S NAME: LIC NO:
t �CONTROL
1�
RC 'CI7ENGINEEft: LIC NO: I
ESS:
CONTACT: PHONE: J ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PL PERMIT ISSUANCELICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIALIOB DESCRIPTION
0047 I herebyeffiren that l am licensed underprovisionsol'Chapter9(commencing with1400 Sectiofall on 7")eofDivision 3 of the Businessamd Professios Cogamd my license is inPANELS riz1{�►\� y
and
FZUpUOy License Class Lic.p-S3 UP T02W AMPS _ •7��i—AV\
m=y
Date Contractor ]01-I000AMPS
O��Zz :r 'CTS DECLARATION SQ.FT.FLOOR ARRA SISQ.F1'.
e 'i tai xh e a ntds� OVER I"AMPS
W n SIGNS ELECTRICAL
g'7d iwnseAW fasiiiin.1
66 Wee< OWNER-BUILDER DECLARATION SPECIAL CIRCUTUMISC.
MF. 1 hereby am.that I am exempt from the Contractor's License Isw for the
uN following reasen.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MITIiR OR POLE INST.
F❑6 which requires a permit to construct,enter,improve,demolish.or repair any structure
prior to its issuance,also requires the applicant forsuch Permit to Glc a signed statement POWER DEVICES
p""J p 0K that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter
04 oLL 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC ^���'``'```���}srkkk VALUATION
or that yNJ'^y Sectioheiseaemptnyapromnt fthe basis for the
ctsalleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES _ _
Z❑Q Section'ID3 LS be hundred
liaaatforapermit subjects the apDli<ennn acivil penalty of LLL�y+r
not morethan ofthedred JollarmyemU. NEW RESIDFNTIALELECIR —SQ.IT.
6m ❑ Lme.,nttoftheplarmu.ormy cmployceswithwages as theiraolecnmpenemimn, STORIES TYPE CON TRUCTION
q willtlolesions ande she Conn roti JedoroflerW for mle(Sec.7044,Business
end Profusions Crile:The Conn rte Licen. Law does not apply to an owner of
property whobuild.sor impure ereon.mu whoisuch workhimselforthrough his
ownemes
ploye ,pmviJedt suchinn,mv emnar mintendedmnfTereJforsale.If. OCC GROUP RES.UNITS
however.,ebuildingo ' provemem ie srlJ withino eyearnfomr,lehim,lhecommo .ro
builder will have tl uothn ofproving that he did not uildorimnoveforpurpsecof
side.).
❑ I nerefthepmpeny,a clusNelycoa wimlicmeadivenvacmrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
rpr
Yet the ojccl(Sec. (H4, us.and sit Code:)The Contracm/9
I
cenxel.awdoeinotapply a fpm hobm sm'mpmvesthcomm,md PERMIT ISSUANCE
ho rontrectsforsuch projcc so t aauole Contraztors ALTER-DRAIN&VENT-WATER(FA) FEE SUMM Y
.Xeon,Law. I
❑ I am exempt un is P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
ter Dme RECE p
K CC9 ENSATIO ECLARATION DRAINS-FLOOR,ROOF,AREA,CONE). SCHOOLTAX Y N
Ihere mathin nificateof asentmrelf-insore,oracenificateof RB :IPfp
mkerx oat sationlns ecoraccriffil copythcmcdf(Scc.3800.1ab CJwhich FIXTURIS-PERTRAP PARK FEE F Y N
n ell empl sunder this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS
Is
opus
P icyq BUIL G (VISION FEES
Cr party GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEP.`T U
Certified copy is herehy fornix J.
❑ Cenifiedcrpyiafiled will city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CPRTfPICAT OF I'J(F.MPI'IDN FROM WORKERS' GREASETRAP SOUS FEE
MPENSATION INSURANCE
( ismonnoecd tbocompletal ifthe permit is(Drone hundred dollars(fI W) SEWER-SANITARY-STORM BA.200FT. ENERGY
or lexeJ
Ice ify that' the pertamm�nce of the work for hich this ermit is issueJ,IshWl WATER HGTEft WryENT/ELECTR
not emplr person so{yyI Y le Wrrk<% PAID
Com f ` WATER SYSTEMITRFATING Recci tp
p P
z O NOTICE.TOAPPLICANT:I,eller making this Cetifi<em of Eaem i n TOTAL:
%n ,you should NEW RESIDENTIAL PLATE, SQ.FT.
ru timmue subjauothe Workers Compensation Provisions nfine Labor Code,you most
7 forthwith comply with such provisions or this permit shall he deemW revoked. �"' BUILDING FEE �..
I3] SEISMIC FEE
qn' Q CONSTRUCTION is ac ION LENDING AGENCY
✓ 7. (hereby hich ibis .it is ecunswee3l97,lendingagencyforthe Performance of
the work far which this permit is issued(Sec.3U97,Civ.CJ TjW. asa— ELECTRIC FEE
IcnJNs Name
u" Lender's Address QTY. MECHANICAL PERMIT FEI7 PLUMBING FEE
U 1 certify let I have read this application and state that the above information is MECHANICAL PER
correct.legree mcomply with Wl city and county nrdinunces end stmelaws rtlatingm PERMIT ISSUANCE
U) buildingeormmuction.and hereby uathorice representatives ofthiscity to emerupon the CONSI'RUCTIONTAX
U above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities'udgmeres s ses which may in any way accrue against said City I AIR HANDLING UNIT(TO 10,000 CFM)
'mm egrant is permit.
AIR HANDLING UNIT(OVER I0,O6o CTM)
Signature of ApplicanUContreaor 'V Data EXHAUST HOOD(WIDUC) PAID
HAZARDOUS MATERIALS recommit
eco DISCLOSURE
HEATING UNIT(TO HKLW BTU) Dote Rmeipt I
Will the to Cupertior no
ture Municipal
Code,Chapter
apemre or hanand the
Health usmatmal HEATING UNIT(OVER 100,000 BTU) T
C defined by the Cupertino Muni<ipd Code,Chapter 9.13,mJ the Health wtl Safety
Code,Section 25512(a)7
CI Yes El No VENTILATION FAN(SINGLE RESID)
ISSUAN E DATE
BOILER COMP(3HP OR I lgdKKl BTU)
Will lhir communires as denied
by the
nBay A .Airt oath cManagement q
hazaNaus o'u<ontamfnents u JefineJ by th<Buy Ante Aar Quality Management BOILER-COMP(OVER IW,IXp BTU)
Diavie? oN/�
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT.
I have read the hadardoux atheists requirements under Chapter 6.95 of the 1 2 19A
California Health&Safety Crile,Seeinns 25505,25533 tM 25534. 1 understand that Cil} Vr 95
if the building does not currently have u tenant,that it is my responsibility to notify the V
.cup.,of the"mocmenu which must 4 mt prio
er m nc
issuae of a Cenibcew of Vf Crr
Occupancy. f�
Owner nr uuthmiaeJ agent Dme TOTAL: ISSUED BY.
OFFICE