28182 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING:ELECTRICAL PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING.MECHANICAL 28182
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
Z2I 10(P /',I bAi -re CoL) R� UNIT
r,LJo
UNIT# LOT H \�
OWNERS NAME: 1� PHONE: CONTRACTOR'S NAME: LIC NO:
RO QE2 � VL.$I LSr7 L,V �'LCiSL N/C CONTROL#
RCH11'ECTANGINEER: LIC NO: ADDRESS: ❑
CONTACT: / PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
EL BLDG ELECT PLUMB MECH
PERMIT ISSUANCE. ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
aZ IhembfB
yarm that lam licensed underpmvisionsof Chapter9(commencing with
00 Section 70(0)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
ass affect,
t.
UPT02MAMPS
Z Licensense Class Lic.#
ti 6 y Dete Contractor -1000 AMPS
Z'sy7� ARCHITECPOVER DECLARATION OVER IUW AMPS SQ.PI'.FLOOR AREA $/SQ.Ff.
O Z— I 1 understand my plans shell he used as public records.
r SIGNS ELECTRICAL
45
6 ,-) Licensed Professional
p�KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OyU) I hereby affirm that I am exempt from the Committees License Law for the
W 30.N following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit o construct,alter,improve,demolish.or repair any structure
} prior to its issuance,also requires the split icant for such permit o file a signed statement POWER DEVICES
4O that he is licensed pumuanno the provisions of the Contractors License Law(Chapter
G O 9(commen' with Section Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
yam erg wl ) VALUATION
yYj❑,n or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 6�C—�-
QSection 7031.5 by any applicant fora pe jecis the appllcarl to a civil penalty of
not than It handrail(S ). .
L Po Lasewaer.fdopmpn,y,o yemployees ithwagesasthei(solecomptasadvnNEW RESIDENTIAL ELECI'R, S QITT. STORIES TYPECONSTROCf10N
will wak, irldestru trumendedo fferedforsale Sec.TW4,Busincss
and Profess ns Code: Commerce's License L does not apply to an owner of
propenywhobuilds mpmvesthereogandwhodoe uchworkhimselforthrough his OCC.GROUP RES.UNITS
ownemployees, videddeasuchimpmvementsereno'reandedorofferedfarsah.IL
howevegthe ildingnrimprovemen 'e soldwithinone rofcompletion,theowner- TOTAL:
buildcrwi avetheburdenof i edidno uildor improveforpurposeof
sate.), QTY. PLUMBING PERMIT FEB FLOOD ZONE APN
❑ ,as owner the t exclusively mecting withlicensedcantmcmrsto
cont m the pro ,Business an Professions Code)The Contractor's
Ursa Law tae manownerofyry'openywhobulldsarimprovesthereon,end PERMIT ISSUANCE
whom rads form pro chswith.coguelor(s)licensed pursuant mthe Contrac'or'e ALTER hA
License (- ) FEE SUMMARY
❑ r xempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE IDE FE.S
SANITARY Y—N
—
Date CO Date DRAINS-FLOOR,ROOF,AREA,COND. CEIPT#
WORKM COMPP.NSATION DECLARATION SCHOOLTAX Y N
,dill Thereby. math have acenifcam of conxnun self-insure,ora certificate of FIXTURES-PER TRAP .CEIPT#
Workers'Compens on Insurance or a certified copy themaf(Sec.3800,Lab C.)which •✓',a PARK FEF. N
oven all employee's under this permit. its
WEI"#lLETS
Policy# GAS-EA.SYSTEM- �WN
BUILDINP DIVISION FEES
Company GAS,Eetl SYSTEM-OVERd( ) {� PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenified copy is Bled with the city inspection division. -• GREASW[NDUS AS I CEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKER�' t•'" - G EAE TRAP,. V' _ 'r SOILS FEE
COMPENSATION INSURANCE ^
(This section need not he completed ifthe permit is for ase h ed doylurs ) SLW2R;5 NFI'A Y- TO FT. ENEpt
or less.) y'SY 'aa
Iccnify that in the performance of the work fm which this pe is is ed, l WATEll TER 1
not employ any person in any manner so es to become sublec m th,,W', PAID
,7-i Compensmion Lawsof Cadfomia. Date WATER LNG -,,,spa Date Receipt#
C) O Applicant
C.) NOTICE TO APPLICANT:IL after making this Certificate of Exemption,youshauld SIDENTIAL PLME�y"/^ SQ.FT.
TOTAL.:
rq become subject m the Worker's Compensation tiis provisions of the Labor e,yo must
� ; Forthwith comply with such provisions or this permit shall be deemed bkW. BUIL E 0�
W F CONSTRUCTION LENDING AGENCY „r,$,Sw- ~ SEISMIC FEEtZ
ttVVq!! 7-" I hereby affirm that there is a retroaction lending agency for the perform TOTAL: ELECTRICO the work for which this permit Is Issued(See.3097,Civ.C.) FIf
LTw Leader Name QTY. MECHANICAL PERMIT FEE PLUMBING EE
>i U I certify that I have read this application and state that the above information is
}' Lender's Address MECHANICk FEE
LTa Correct.lagmem comply with all city andemal,nrdinancesandmate laws relating m PERMIT ISSUANCE
.Fi building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRU ION TAX
U 7 above-mentioned prnpeny for inspection purposes. ALTER OR ADD TO MECH.
Z
(We)agree to save,indemnify and keep harmless The City of Cupertino against
liailities,judgments,costs and espouses which may in any may.ccmeagainst said City AIR HANDLING UNIT(T010,000 CFM)
na acne o[t r ins M1ls permll. ;�
T AIR HANDLING MT(OVER 10,000 CFM)
Signature of Applicant/Contramin W Date EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Roceip,
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100.000 BTU) A
Code,Section 25572(0)^
❑Yes ❑No VENTILATION FAN(SINGLE RESID) I
BOILER-COMP(3HP OR 100,000 BTU) �IS$ ANC DATE
Will air pplicantorfnturs building by the
maseequipmir Quality Managemch ent
9 ftp
hazardous air conmminnnts ns defined by the Bay Arca Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU) B/
/,gyp ] A
❑Yea ❑No NEW RESIDENTIAL MECII. SQ.FT. yy11�/ /I 1 4
I have read the hnsablous materials requirements under Chapter 6.95 of the V�/� 'Uh 'e' 19 95
Califumia Heelth&SafetyCWe,Sxdo.25505,25533.nd25534. 1uvdersmndfird Lut,` v�(y
if the building does not currently have a meant,that it is my responsibility to notify the C
acupam of the mmieements which most he me'prior m Issuance of a Cenificmo of
Occupancy.
Owner or authorized agent Data I ITOTAL: ISSUED BY:
OFFICE