28346APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
RU I I,DIN(;- ELECTRICAL
PERMIT NO.
APPLICATION/PERMIT
PLUMIfING-MECHANICAL
28346
BUILDING DIVISION
BUILDING PROJECTIDEN'nFICAI'ION
BUILDING ADDRESS:
SANITARY NO.
AM.ICAAJ'rTION SUBMITTAL DATE,
UNIT» LOT
OWNERS NAME: PIIONf::
CO/B/TRACTOR'S NU: LICNO
N/C
❑
COMROh»
1/TG S%'4o78 (ter— Ol PI I 9�
ARC ITIiCI'/IiNGINEER: LIC NO: ADD RPIS (9"q — _IvWI
5 /I N(/
CONTACT': PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMITINFO
HLDG ELECT' PLUMB MHCII
PERIMTISSUANCB
11 `f'�
LICENSED CONTRACTOR'S DECIARA'I ION
APPLIANCES - RESIDENT 'IA).
LOB DESCRIPTION
r 9lcnmencing with
I hereby uffnn that 1 am licensed under powkinnsnfCtupmm
Sectimt Man Of Division 3 of the Bu,imcs,und Probo,inns Cob,and my license is in
PANELS
! 1
full Immoral effect.
IJmnw Clues Lia»
UP T0200 AMPS
1`"
Date Contractor
201 - 1000 AMPS
ARCHITECPS DECLARATION
OVER 1000 AMPS
SQ. FF FLOOR AREA
$/SQ. FT.
I understand my plans that bused as public sordes.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUTUMISC.
1 heathy affirm That I an exempt from the Comracon, License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
which m,rim, a pctmit to ennnmm, alter, improve. demolish or ¢pair any swmure
prinnnila isswnce, also rcyuires the applicant for such pemtiltn fidrusignedsattmenr
POWER DIiVICIiS
t hoe he is licensed pursuant to the provisions olthe Corrummra License Law(Chapter
VALUATION
SWIMMING 1'001.13LLCT'RIC 9(cw ring withSmion 9000pd Divisinn3o11he Onsinenx unA Pofeuions Code)
of That he k racntpt thcrcfmm and the basis for the ullcgcJ exemption. Any vinlaion ofV
V
�Seciion7031.5 by any applicant for a permit subjects the applicanna a civil penalty of
OUTLHIS-SWIi'CIIES �II%'TURES
Y� i�V ..
not mom than five hundred red as($500).
NEWRESIDEMIALELECTRSQ.FT.
STORIES
TYPO CONSTRUCnON
E)fi I,asowneroepropcny,ormyemployces with wagesextheirsolecomceasation,
will do the work,and thesememm is not intended orofound formle (See .]094. Business
and Pmfevaona CWc: The Contreaors License Low does not apply toe an owner of
pmpenywhobudilsorimprovestheteon.end whadoes such work himmlfor though his
OCC GROUP
RIS. UNITS
employecs.pmvided duuuchimpmvemrt entsenot incndisoroffered formle. If.
however, the buildingor improvement is sold within one Yea ufcompletion, the own e,
TOTAL:
builder will have the burden ofpmving that he did not build m improve for purpose of
sale.).
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
ANN
dcomcums to
[1 1. a% ownermrhe property, am exclusively contracting with licenmm
omtrum the potpo (Sec. 9094. Business and Plnfcmions Cade:) The Cmntmnm's
Licenu lawdoes noel apply to an ownerofpraptny who NO16 t imp roves0cmmrmrd
PERMIT ISSUANCE,
whit contracts for such projects with seminarians) licensed purmanuo the Contractor's
'-
Lice se Law.
nl
ALTER- DRAIN & VENT WATER (EA)
FEE SUMMARY
❑ am oncnpf nndcr Scc. , B & P C for This reason
PACK FLOWI'RO'l1iCl'. DEVICEO
TSIDI: ES
FE
SANITARY Y N
RECEIVI M
Owner Date
WORKMAN COMPENSAMONDF:CLARATION
DRAINS FLOOR, R OND.
SCHOOLTAX Y N
❑ I hereby affirm that T have acenificam ofennsmnl toself-insme, or acenifivere ofFl%TURL'S-PE
'RAP
RECEIPT'»
PARK ME Y N
psation loarrommora cenSec.3800, ifedcopythorcof(Lnb C.)which
Workers' Comen
LO—
covers all employer's under this Permit.GAS-EASY
lint -I INCA OUTLETS
RECEIPT'»
BUILDING DIVISION IBIS
Policy M
Company
GAS - G. SY TEM -OVER 4(EA)NCHF,CK
FEE
❑ Certified copy ishemby famished.
=GIRAVING FEE
❑ Cedifed copy is filed with the city inspectiondivision. GREASFJIN USTRLWASTEINTE OR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE, 4AP
OILS FEE
COMPENSATION INSURANCE
ENERGY FEF,
(Thisxection need not he completed ifthe permit is nature hundred dollars(SIM) SEWER ANITARY- STOktM EA.
or Iesa.l
I certify that in the perhomlance ofthe work for which this pemtit is issued, I shall WATF. HATER W/VENT/ELE
not employ any person in any manner in to. to hoemne subject to the Workers'
PAID
COmpcns:nion Luwsor Califnmiu. Date
WAI'E SYSTEVbT VATING
Dam Rtceipt»
Applicant
TOTAL:
NOTTCHTO APPLICANT: If, after makingchis Cenifcaleof Exrmption, you should NEWRE DENI'IALPL SNF/
mp provisions) Labor CWc,you man
bcnmmit
bthe
fnnhwith comply with such pmvisiom Or this pemtit shall b deemed revoked.
complywithor his
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hcaby affirm that the. is a connmaian lending agency for the performance of
the work for which this permit is issued(Sec. 3091. Civ. C.)
TOTAL:
ELECTRIC FEE
PLUMBING FEE
�O% Ub
Lcmises Name
lenders Address QTY. MECHANICAL PE IT FEE
I candy that 1 have mad this application and state that the above information is
MECHANICAL PEE
acct. l agree to comply with all city aed county ordinances and stoic laws redoing to
PERMITISSUANCE
CONSTRUCTION TAX
building construction, add hereby authonzt representatives of thiscity to enter upon the
abve mentioned property far inspection purposes.
ALTER OR ADD TO MECIL
(We) some it, save, indemnify and keep harmless the City or Cupenino against
habilitiesjudgmenls, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10.000 CFM)
G1( rye
in consequence Of the grunting Of this pcovit.
AIR HANULINC UNIT (OVER IO.fg) CFM)
O
PAIDQ 88y
Signature of Applicata/Cordow, Dae EXI IAUST HOOD(W/DUCT)
Date Receipt»
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU)
TOTAL.:
/(7
Will The applicant or future building Occupant store or handle hereadous material
HEATING UNIT (OVER 100,000 BLV)
as defined by the Cupertino Municipal Code, Chapter 9. f2 and the Health and Safety
CWe, Section 25532(a)P
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
VISSLIANCE'DATE
BOILER- COMP(3HP OR 100,000 BTU)
Will the applicamorfumre buildingmccupant mreeyuipatemmdeviceswhichtndt
torrents air Oixi minors as defined by the Bay Area Air Quality Msnagemtm
BOILER - COMP (OVER 100,000 BTU)
25
DisWa9
AUG 1995
❑ Yes ❑ No
NF,W RF_SIDENTIAh MECtI. SQ. Ff.
1 have read the misimanus materials ov,mmments under Chapter 6.95 of the
CITY Ur CUPEHTiNO
Califomin Ilemlb & Salety Code, Sections 25505, 25533 and 25534. 1 made caand that
Ir the hullJing dues not cercntly have a tenant, that it is my respansihi Illy to nmlfy the
nccopam of the reyuircmcnts which must la, mel or... to issmarla of u Certificate of
(kcuponcy.
T
ISSUED BY' /me—/-ri_
Owner or authorized agent Date TOTAL:
OFFICE