28137 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B RTEsi;-ELECTRI AI. PBRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
NUII, LII ' I V BUILDING PROJECTIDENTIFICATION
DING R{ - tt\ `iS�l'f SANITARY NO. AYPLICATIONSUBMITTALDAIE
IF
l" S K�� l�Y L V II.Q I{�OI�'IUNIT tl` 1 LOT It
HERS NAME: ���-pp PHHONNE: CO ACTOR'S NAME: LIC NO:
Lj1/L 0.M 11�p &, ` O lO NIC CONFROL9
kC1il'I'E /ENGINEEk� LIC N13 A ESS: ❑
495
corrrncr: PHONE: BUILDING PERMIT INFO
�'3 E�S�a) QTY. ELECTRIC PERMIT FEE
1111 Wy BLDCr. EhECI' PLUMB MECH
CIIL'1 PERMIT ISSUANCE ,CT����(/sl��q`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-REMDEM'IAL
nyZ Ihembyaffrn rhatlamlicenses under prvvisivnsvfCTaptv9(mmmrncingwith
(v00F Scaion 7000)of Diidoon 3of the Business and Professions Cade,mom,license is in PANELS
z Z W full force and erten.
co<;o. License Class Lic.p UP T02W AMPS
v=oo Date Contractor 201-IOW AMPS
F y Z A I ECFS DECLARATION SQ.IT.FLOOR AREA S/SQ.F 1'.
ndcmmnd my plat' sp "'mm'. OVER INS)AMPS
I-v1F Wor- SIGNS ELECTRICAL
messed Professiotul
2CyzQ OW IiR- L DECLARATION SPECIAL CIRCUIT/MISC.
KOdU 1 hereby,vfEtm that I am eaempctors l from the ConveLicense Law for the
WDA_ ibllowingrcasan.(Seen 17031.5,Business and Professions Cade:Anycltynr county TEMP.METER OR POLE INST.
F--y; which requires a permit to crmsvua,alter,improve,demolish or repair any strucmrc
"V ;F prior m its issuance,also requires theapplicvmt f rtnal Glresignalstsmment POWER DEVICES
W C Q p that he ie licensed isions of the Contractor'.License Law(Chapter
Dido= 9(comme - gwith Secti.n]IKKO of Di�s on Sof the Bu.vines.anJProfessime Code) SWIMMING POOL ELECTRIC VALUATION
co varier is eaempvherefrom and the basislfor the alleged ex e plion.Anyviola"ionof
FZ_y' See 17031.5 by any applicant for a permit suhjecb(heap pii ant to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
I mom than five hundred dollar(SSW). S
�= NEW REMDENTIALELECTR 5 FT'
❑ Lasnwnerofrhepmperty.ormyvnployeeswirh wages heirsoleeQ omperesalion. STORIES TY PE CONSIRUC'I"ION
Is will do the work.and the smiciam is nor lnmndedoroffered forale(SecJ044,Business
Com
and Professions Cade:The Coevor's License Law does .r apply to an owner of
property who buildsorimprovcs thereon,and whodocs such mKornselforthroughhis
employees provided than sachimprovemenr.arennrim adedmoffefedfnrsale.If, OCC.GROUP R15.UNITS
however,the building or improvetrrcm is sold within oxeye of completion.lheawner-
butlderwill have The Its rd of pro ing that le did net bol or improve lot purpose of
wm.). TY. PLUMBING PERMIT FEE FtoaD loNE ArN
❑ I,usnwn of the Pr 1 cl omnctin w It he tmcmom Q
c.nalmaY rhe ofesa' s C: :)T1e nfac or's
License La c ape" o e' fpropcny wilds improves tier nand PERMIT ISSUANCE
whocnntae sf ` uwimaeomracto eerased toms.the C.no- tn's
License ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 im exam dv Sec. B&P C for this re BACK FLOW PROTECT,DEVICE OUTSIDE FRES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF.AREA,COND. RECRUIT#
RK COMPENS�� NDECLARATION SCHOOLTAX YN
❑ Iherebyuffiam th tihave cenif�nf mnsem".self-innure,nracenilicmeol' FIXTURES-PI2R TRAP RECEIPI'p
Workers'Can-1-d'ion Insurance unified copythereof(Sec. W,Lab C.)wbich PARK FEE Y N_
rsalle yee'aunderfiisunit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECF,IPTk
Policy p BUILDING DIVISION FEE
Co ny AS-EA.SYSTEM-OVHR 4(EA) - PLANCHECK FEE
Cmificd copy in herchy fu 1isM1eJ.
❑ Testified copy is filed wish e<ity inspection div'1s n. 1'R IiAS4/INDUSTRL WASTE INTERCEPTOR
k/\\ GRADING FEE
CERTIFICATED 13XEMP1'ION FR W ERSGREASETRAP SOILS FEE;
COMP SATI INS
or less.) ,urchin need no"be cont IctWi tape hi, mon hunJrN dm ($I ) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
I certify that in the perfmmunc ofth rwhichNs��illrisissu shall WATER IIEATER W/VENT1ELECfR
not employ any pavan in any m 1 me v b t 10 the Orkeri' PAID
z Compensation laws of California. a ne WATER SYSTF,M?HEATING Date Receipt N
Applican"
� Q NOTICF,TO APPLICANT:ILnf¢rmkingth'i nificare of Excir n,you should NEW RESIDEN'T'IAL B. SQ.14. TOTAL:
V1 becumesubpe,mine Workers Compe -cion provisions o"be
La Code,you mus"
> Rlnhwirh comply wi'll such pore,00as� this permit shall be doo ed revoked. BUILDING FEE
_ I.7
G Q CONSTRUCTION ENDING ADEN SEISMIC IRE
z Ihereby affirm that here is a coeho tion lending ag ey for die performance of
U O rheworkforwhich Nispertnitisissucd(S .3W7,Civ. .) I ELECTRIC FEE
Icndcev Name
0 U Lendds Address QTY. MECHANICAL PERMIT FEE PLUMING FEE
1 unify that 1 have mad this application Stara that the above information is
�"' 0. vomer. Ingrecmavnply with all city and county nrdinwees and clam laws rclaGng"v PERMIT ISSUANCE MECHANICAL FEE
F' h building construction,and hereby amhnrize representatives of"hi.s city to enierupon the
U .z dxvvomemmmdptopeny for inspv"ion puHrous. ALTT:RORADDTOMECII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hamlcs..the City of Cupertino against
liabilities,Judgmeats st ander n swhichmryin any wag accmeagai IaviJCi"y AIR HANDLING UNH(TO I0.0WCFM1
assist f spemit.
I AIR HANDLING UNIT(OVER IQ0W CFM)
"grams of Pry /'ommn: Dare EXHAUST HOOD(W/DUC l
PAID
Int or OUS MATE RIALS DISCLOSURE HEATING UNIT(TO W,Wp BTU) Date Receipt#
Will the applicant or'woreicipbuildingl meopulat tClotperre or handle Health and Safeal
mre.S dby the Cupertino Municipal Code,Chopmr9.l2,and the l"as"h and Safety HEATING UNIT(OVIiH]fit)WO BTU) "TOTAL:
CWc.Seninn 25532(a)!
11 yea 0N VEM'ILATION hAN(SINGLE RESID)
Will the acontamina future building by the Bay equipment oadevic Management
BOILER-COMP(3HP OR 101,0011 BTU) ISSUANCE DATE
Courus air contaminants as defined by the Pay Area Air Quality Management BOILER-COMP OVER 100.000BT
Divodcr! l U) � '
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have cars the hateardim,trla evials milmo mems under Chapter 6.95 of the ��/ �O
titebuilding
ondo&Safety Cculeendly have
a res ant,that
it is andocips, . (understand than n e'I
Californiaaheria Health
heveamnan5,5.2553my 25unsibilirymnotifyrhe �'y}''1'/p`fYAf^/�C/,
'cul a ll ol'the requirements which must be met prior to issuance of a Certificate of U
Occupancy.
Owner ur umhorved agnn Date TOTAL: ISSUED BPC O
OFFICE