28203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI 11 ILUIrNf:-ELECTRICAL PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL. !�O /�O
BUILDING DIVISION BUILDING PROJECIADP.NTIF'ICATION L o G
11LDIN(1 AUUHI?SSG_ /r/1 � /, l /[ /� /� �/�J SANI'T'ARY NO. A/Ih'LICA'I'It1Nj—SUl/Na�Mf1'I'AL DA IE
�S / V D�VV �L.i Y(�W�F{N LOTH
NEH AMIi: a / PfIONFt- CINTHACIOR'S NAME: LIC NO,
N/C CON'1"ROLA
CHHECf/ENGINEER: LIC NO: AU F:SS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Q'fY. IiLECTRIC PERMIT FEE
B Ii1.liC1'_ PLUMB Mh❑CII
\
PERMIT ISSUANCE. �TCAJ[—
LICENSED CON'fRACTO visime.fChat ON APPLIANCIiS-RIiSNENI'IAI. 1 BDESCRIPH
py.Z IherebyaffinmbaG 3 ofm Bussed iness
and Professions
Coder and mmecense with (l'1
,1 W 5 In][fore mul d cert. on l of the Rusineswnd Professions Code,and my license is in pgNBfS ✓(
Fy�41 ffes-.. roll force ane cffmt.
U LJ
sill" Data Claes Lic.p UP TO 200 AMPS
ti 61
Data Co..,.,TS301-1AMPS
Fv— ARCHITECTS DIl1iCLAHA'I']ON 000 OVER 1000 AMPS
OZ-0 / SQ.17.FLOOR AREA b/SQ.PI'.
Z O`� 1 understand my plans shall he used as public records.
SIGNS ELECIRICAI,
Licence)l'mfnsiowl OWNER BUILDER DECLARATION SPECIAL CIRCUI'DMISC.
xCdxOyU I hereby affirm that I am exempt from the Convecmrs License Law for the
y13 trrr following resod.(Seninn]031.5,Business and Profession,C de:Any city mc....y TEMP.METER OR PO.•INST.
F�• Q' which requires apermit nconstruct,after,improve.Jcmolish,ormpalr any stmemre
}2 prions its issuance,also requires the applicam for such aronitm file.signedstatemem POWER DEVIC"
K that he is licensed pursuant to the provisions of the Contmcmes License I'aw(Chapter
d IoW Ycommmtcin ) SWIMMINGP OLELECfRIC
( gwith Section 9fgOpd Division Business and Profcs,iore Crde VALUATION
^m or that he is exempt hcmfrom and the basis for the alleged exemption.Any violation of
FZ_a Section 7031.5 by any applicant for a pennitsubject the applicant to a civil penalty of OUT-ET -FlXTURES
xthan five hundred d.11...($50B. NEW ESIDENTIAI.ELECI'R _SQ.IrU
1'Fo ❑n Lrc asowncroftheprnpeny,ormyemployceswithwagesaathcirsolecompencation, STORIES TY I'E CONSITUCI'[ON
x3222 will do the work.and the abucture is not intended or offered for sale(See7u 4,Business
and Profession,Code:'I he Commanr,License Law doe,not apply to an owner of
property,who builds or improves thereon,and who doessuch work himselfor thri his
' wnemployres.provided thasuch impmvcmemsartnm imendedoroffcredfmule.IL OCC.GROUP RBS.UNITS
however,the building or impmvcmew is sold within one year ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,asowncmfth<pwpeny,am exclusivelyconvuning with liven The Cimonchns
onstract the pn'ject(Sea.9044.Business and Prefe,sion,C'ndcJ Tt¢Contractor's
Li cense Lew celesnot eppl,toanownerofpropcnywhobuildsm imprevesthereon,and PI[RM11'ISSUANCIi
who can fncwcmmojects with anomracmrts)licensed pursuant to the Contracmrs
Licce'.law. ALTER-DRAW ENT-WATER(s ) FEESUMMARY
❑ I am exempt under Sec. .B&P C for this mason BACK P.01rV PRO'I ECT.DEVICE OUTS I UE FF[IS
SANITARY Y N
Owner Dale AINS-FLOOR,ROOF,AREA,CON D. RECEIPT,
WORKMAN COMPENSATION DECLARATION SCHOOL]AS Y N
❑ Thereby affirm thatl haveacenificam of conunuo xlGi...ril racenifiedecd FlKTURES-PER TRAPRECEIPT,
Workem'Coefensation Insurance or a certified copy thereof(See.3800,Lab C.)which PARK FEE Y N
mnllempinydsunder thin permit. CA(1CILETS RECEIPT,
GAS-EA.SYSTEM-I IN
Policy Y BUILDING DIVISION PEGS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CcnipeA copy is hereby fuminhed.
❑ Certified copy is fled with the city inspection division. GRMSEAN13 LWASIBIn-W11IFOR GRADING IEE
CERTIFICATE Oil 17.%F.MPf10N FROM WORKERS' EA SOILS FEE
COMPENSATION INSURANCE
This section need not be completed ifthe permit is for one hundred ollam(b100) S ANIT Y RM EA.300FT. ENERGY HE
se.l
I certify that in the perfonnunee of th<work for which this permit is ued,ls I ATER > TIJ} VENT'/IiLECIH
not employ any Persian in any manner so as to hecume subject to a WOA PAID
Compensmimislowaof Califomia. Date WA S lEM/rREATING Dam Recei p
O 'Z. nppue:mm
0 NOlicant APPLICANT:If,after making this Certificate of fxcmption, ou should NEWRESIDENTIALPLMR. SQ.FL TOTAL:
HCo become subject to the Worker's Compensation provisionsofthe Labor Code, o must
> fortbwint comply with such provisions or this permit shall be deemed revoke BUILDING /+
Ul " SETS 'EE
❑
CONSTRUCTION ION LENDING AGENCY
Z
I hereby affirm that there is a construction lending agency for the performun of /
U the work for which this permit is issued(See 5099,Civ.C.) FI. C 7.E
Lender's Name PLUMBING
u' F Lenner's Address QTY. M HANICAI.PERMIT FEE
U I certify that 1 have rend this application and stare that the above information i, MECHANIC FEE
corsca't. lagrre mcomply with all city and county eminences and stem laws relatingb PER SSUANCE
building construction,and hereby authoriru c u Imivesofdancitymemerurymthe CONSTR ON TAX
U Z abnveneminned pmperY far in, tion rrpnu. ACI'ER OR ADD TO MECII.
e).gree m save.iad kap ss the City of Npenino against
judgmcnts,anI dente swh' y in.aywayaecme against said City AIR HANDLING UNIT CTO I400(ICFM)
I coc of the gr: in t i,
AIR HANDLING UNIT(OVER i0.0tg1 CPM)
ignumme Apphcan(/Corlr 6r Date 17XHAUST HOOD(W/DUC) /
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0i BTU) Date Recei, g
Will the applicam or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I lculth and Safety I]RATING UNIT(OVER 100,000 BT U) TOTAL:
Cede.Section 25532(x)7
C)Yes ❑ No VENTILA'T'ION FAN(SINGLE RESID)
ISSUANC DATE
Will the applicantorfumrcbuildingercupant useequipmentordevices whichman BOILER-COMP(3HPOR I00.00(19'1'U) P
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL M[CII. SQ.IT. (/ i]7
1 have mad the ba mom.,materials re,pincmcnts under,Chapter 6.95 of the C//is ` I Gj l9g
Califomia Heahn&Safety Code,Sections 25505.25533 and 25534.I understand.hat /,
ifthe building coca nm currently have or an,thatn is my responsibility to notify theLU&-
mupant of the mgad iremcnwhich must the met prior to issuance of a Carl i ficme of M/6
Occupancy.
Owner or authorize)agent ,are
TOTAL: ISSUED BY.
OFFICE