28230APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING IWOJECI'IDF.NTIFICA'1']ON
PF.RMITNO. ^ ^ ^ ^ O
L lXJ L J{
.?BUILDING ADDRESS:
105,111t1\r4 V0 UNITit LOT#1-6
SANITARY NO.
�SUBMITTAL
APPLICATION
L DATE
O SN ME: PIIONE
-KsopZT2-S-O�
N7RACTOR'S NAME: LIC NO:
QW h 4111
N/C
❑
CONTROL#
I�
ARCI I I'ITCT/IiNGI ':R: LIC PA
ADDRESS:
CONTACT: PHONE:6/
QTY. F.LECI'HIC PERMIT' PEB
BUILDING PERMIT INIG
BI. G ELECT rIUMOMjiCll
or -iii ti\`
PERI
MIT
LICFNSI,D CONTRACT'OR'S DECLARATION
hereby affirm that I am licenscd underpmvinionsofChaper9 (commencing with
APPLIANCES - RESIDENTIAL
TOR DESCRIPTION1
PANELS
Section 7001Bof Division 3 ofthe Bnincesand Professions Code, anlmy license is in
full fdicer.
Liceine Class ir. p
OPT0200AMPS
iV Q
Dom COmma
201 - I(al AMPS
ARCHITECTS DECLARATION
1 understand my plans shall h used as public records.
OVER IBM AMPS
SQ. FT. FLOOR ARIA $ISQ. PT.
� . /� CIEtz
VN
SIGNS EL
ELECTRICAL■�Jlte�—�{r
M
Licensed Pmlessional
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractor. Licenm law Teethe
TEMP. MLTER OR POLE INST.
following ii (Section 7031.5, Business and Professions Code: Any city or county
which termini a permit to em,hot n, olte , impnwe, demolish, or repair any structureprior
to its issuance, also recimics the applicant for such permit m file a signed statement
POWER DEVICES
that he is licensed pursuant o the provisions of the Commences License law (Chapter
1)(commencing with Section 7") of Division 3 of the Business and Prmfessimns Code)
or that he is exempt therefrom and We basis for the alleged exemption. Any vial tion of
Section 7031.5 by any applicant for a Permit subjects the applicanno acivil penalty of
SWIMMING POOL. ELECTRIC
VALUATION
1
b
` UTLEIS-SWITC1113-PI%TUBI?S
not more than live hundred dollars (5500).
❑ I,asownerofthe propsny,ormyemployees with wagerestheirsolecompertsation,
NEW RIESIDENTIALELECfR _SQ. 19'.
STORIES
'I'YPECONSTRUCTION
will do the work, and the suucture is not Intended oroffered dorsi de (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property whohuildsorimpfoves thercomand wh.docastichwork himselfor through his
Wempioyces,providedlhat such impmvemcmaae nm intentledor offered Tarsale. If.
OCC. GROUP
RES. UNITS
h Cvp, the building or lmprovnlam it sold within one year nfoompletion, the nwner.
builder will have The burden of proving that he did not build or improve for purpose of
QTY. ING PERMIT FEE
salt.).
❑ Las owncrofthe pmpcny.amexclusively contracting with licensed contractors to
FLOO ZONE
APN
nneuet de prejeet (Sce. 7044, Business and professions Code) Tac Contructm'a
License Law dive not apply to an ownef of propcny who builds or improve thereon, and
PI:R 1' S CE
%invoctaculir such projects with a cmnamforD) licensed pursuant Contactor.
License L.W.
ATR D •NT-WATCR EPA)
FEE SUMMARY
[31 am exempt under see., B & P C forma reason
B LOW PRO T . DEVICE
OUTSIDE I:.
SANITARY Y
RI?CEIPTp
Owner Date
WORKMAN COMPENSATION DECLARATION
R.ROOF, ARFA,COND.
SCHOOLTAX YN
❑ I hereby affirm that l have acmlficaeofcoment mscir-asure,or seeaificainof
WOrkera Compensaion Insurance Or u ccaified copy timanf(Sec. 38M Lah CJwhich
RECEIP p
FIX RP TRAP �/
PARK FEE Y N
rovers all employee's under this pemtit.
Policy#
GAS -FA. YS INC. 40 LETS
REC. PTp
REAPING DISION FEES
Company
❑ Ceaifed copy is hereby famished.
GAS - HA.SYS 'M -O R4(1.
x
PLANCHECK FIi
W) 1111
GRFASFJINDUS NTGRCEPTOR
❑ Ceaif¢d copy is fled with the city inspection division.
GRADING I'
CERTIFICATEOFEXI?MPfION FROM WORKERS
GREASETRAP
SOILS FP
COMPENSATION INSURANCE
SEWER - SANITARY - STORM FA. 2018.
(This section need not be completed ifthe permit is foronehundrW dollars ($100)
Or less.)
WATER HATER WNENT/ELECTR
lcertify the in 0e performuncc of the work for which this permit is issued,lshull
not employ any person in any more, so as to become subject to the Wnrkcrx'
PAID
Compensation Lawsof Culifomia. Data
WATER SYSTEMURFATING
ate Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Ceaifcae of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject m the Workers Cmia, atiom provision of the Labor Code, you must
forthwith comply with such provisions or this Permit shall M deemed invoked.
BUILDI FF.E aha
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a ro ono, inn lending.grey for the performance of
the work for which this Permit is issued( Sec. 3097, Civ. C,)
T[ �w
ELECTRIC FEB r.
landels Name
Lender's Address
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
I cenify that I have read this application and sine that the above information is
Cal agree to Comply with all city and county ordinances and state laws relating m
building construction, and hereby authorize rapreenam
sdves of this city to upon the
ub.ve-mentioned property far inspection purposes.
PERMIT ISS DANCE �.
MECHANICAL FCL:
ALTER OR ADD TO MECH.
CONSTRUCTION TA
(We) agree t. save, indemnity and keep harmless the City of Captain. ugainet
liabilities' B, costs wadexTIA which may in any way acconagainst said City
AIR HANDLING UNIT (TO 10,000 CFM)
I se ram It sperenit. /•
/`J
AIR HANDLING UNIT (OVER IO,(KKI CFM)
:ignam ofA VCo racer ate
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT IT 0100,000 BTU)
HA'LARDOU$ MATERIALS DISCLOSURE
1�dl
Data R eipt p
Om upplicam or fmurc building occuPum store or handle haurdous maerinl
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
II3ATING UNIT (OVER I W,dW BTU)VIAL
VENTILATION FAN (SINGLE BESIDE
Carle. Scmiaa e)i
13 Yet, 11 N.
Yes
WilHhou lienor nrfmorchuildin ecu amuse mrdevicev which emit
PP g P equipnen
mardoa, air cmnaminaats as defined by the Bay Arcu Air Quality Management
isMn7
a s CE D 7'E
-
❑01LI?R-COMP(311P OR I(k1,1gt013TU)
HOILF.R- COMP (OVER 100.000 BTU)
❑ Yes No
CI
1995
NBW RCSIDLNTIAI.
1 have and the hmvdmn materials requirements under Chapter 6.95 of the
snofcur Code, Section 25505,25533 and 25534, 1ilytonatd a ha
it the uldinm. doesthe
ifthebuildingdoesnot currentlyhaveast
theitd myssuanceof a
enotify
he
Occupant Of the requirements which must Fa ton prior to issuance of a Certificate of
Occupancy.
������}/y/��.
ISSUED BY
Owner nnnnhorized agent Date
(r
OFFICE I -