28228APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Y OF CUPERTINO BUILOLNG-ELEC'I'RICA],
APPLICATION /PERMIT PLUM Nc-.MECDANIGAI-
UILDING DIVISION HUILDING PROJF-CT iBENTIFICATION
PERMI'TNO, 2
L CjJC -LJ 'LJ Oji(
DING ADDRESS:
SANITARY NO.
APPLICATION SUBMTITA]. DATE
p t�T
o3 1 R*113t L V I s i A "V/ DNI'I'M 1,01 #G'
— 3�^ ��
NAME: PHONE:
ENAL nPITEC
CONTRACT'OR'S NAME: LIC NO:
Ni
M
CONTROL#
VFO�WNIERS
IENGINII: LIC NO:
ADDRESS:
"1115411— p M � llltA+ 4. 1N -S 4 ly VA L£
LTJ
CONTACT: PHONE:
KATEEN6MLF32�1-t-C
C-1u6 clq 4-_ p
QTY. ELECTRIC PERMIT FEE
BUILDING
BUILDING PERMIT INFO
ELG PLUMB MSH
❑
PERMITISSUANCE ,�
0 ser 7
LL100
CC( W —
FZtw
y6y
Fyy
Z Om"
FLif-W
LICENSED CONTRACTOR'S DECLARATION
1 hercby a0irm thm I am Ilansed Salefr,awkiia s oCh iNcr9 (commencing wlll,
Smian 2(100) of Division 3 of the Business and professions Cade, and my license is in
full force anda t,
License Class Ili Lie.# bZSV �LI
C.-MOR Cir
APPLIANCES - RESIDENTIAL
JOB DESCRIPI'TON
�"% /�-/i [. S•V
PANELS
UP TO 200 AMPS
Date Contractor
ARCHITECTS DECLARATION
I undmilmid shall be used in,ala a records.
ypamsu
201. 1000 AMPS
SQ.IT. FLOOR AREA
$6Q. Pr.
OVER 10(#1 AMPS
SIGNS ELECTRICAL
Licensed Podesvionll
KC"'
x0e.
WiLL o¢,ii
OWNER BUILD17R DECLARATION
I hereby affirm but I am exempt from the Ci mm ma's Littna law for the
following rensort(Section 7031.5. Business and Professions Coda Any city orcounty
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
0_1
�i�a7to
C
W — O
as ori
�_,
CZQ
C F_o
e, °,.°
which requires a permil to comauct, uhe,, improve, demolish nr repmr any smardam
its issuance alsoo es thea licantfim,uch uofile.si donemem
poor qu' pp Tenni gee
the, he is licensed porsaaat to the pmvisions of oto Commutols License Law (Chapter
all thathendng with anfinn211f1()of Division 3ol'the Busincesand Professions Cod.)
of
Sor ectiohcisesemptnyappomand the basisfar bjeasegedesemptt to civil
for aannitsubjeuts,hempplicantmucivilpenalty of
no, mom than five hundred dollen ($Saps
notmmthnbya hundred
❑ I.asownerofthepmMay,ormycmployecawi,hwagesas,heinolecompemation.
will dome work, and the stmmum is not imendedoroffemd forsale(Sm. 2044, Business
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS- SWITCHES - FIXTURES
W
NEW RESIDENTIAL ELECTR SQ. ET.
STORIES
TYPECONSTRUCIION
and Professions Code: 'I'he Contractors License Law does not apply to an owner of
property who builds or improves Ihemon, and who dos such walk himself or through his
con employers, provided that such impis maarcno, earofo proffered far.Iran e. If,
,JCC GROUP
RFS. UNITS
TDTAI:
sold
of proem insa hedi inone t build of completion,turposef
builder will have the burden of proving that he did not build m improve for purpose of
huilder ill have the burden
QTY.PUMBING PERMIT FEE
FLOOD ZONL
nPN
salt.).
❑ I, us owncrafthe pmpcny.sem exclusively <nmmoaing with licensed cnntmcmn,o
ooh
concoct ,he project (Sm. 2000, Business and Professions Code.) The Contractors
xel.aw does no,upply manownerafprnpeny who builds ar im,mam,,hcreon.and
uttn projects will, scomradorts)licensed pursuant to the Contractor's
Ito. rorwcM1
Lntto.law❑
NCE
N&VEN-WATER (EA)
PF:C SUMMARY
1 am exempt under Sec. , B & P C for ,his reason
DEVICE
UTSIDE FE.ROTECT.
SANITARY YN
RECEIPT'#
Owner Date
OR.Rmren ARFA.COND.
- WORKMAN COMPENSATION DECLARATION
❑Ihemby affirm that) havcaccrilicute ofnmscnnn self-insure. ora cenificale of
Workers Compensation Insurance or a clarified copy thereof (See 3800, Lab C.) which
's made, this permit.
cover, all employeed
Poi cy p
SCHOOL TAX Y a N
RLCEIPTp
FIXTURES-PER'IRAP
PARK FEF. V N
RIVISIO#
GAS - EA. SYSTEM-1 INC. 4 OUTLETS
BUILDING N PEES
DIVISIO
Company
GAS -EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified cagy is hercby famished.
GREASRHMUS1'RL WAS TE INTERCEPT OR
GRADING THE
❑ Cenified copy is fled with thecity inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY -STORM EA. 201
ENERGY HE:
(his section need not be completed ifthe permit is for one hundmldollars(SIM)
or le".)
WATER HEATER W/VENT7CLECIR
I cenify that in the perfamtance of,he work for which this permit is issued. l shall
o z
Z V)
not employ any person in any manner to as I. baore rob' t m the Workers'
Lmpcma / `30—Q
ANN9LF! dam--- h Id
NOTICF.Tje.1. APPLICANT: IL after Cenificataof Exemption, au
WATER SYSTEM BEATING
PAID
Date Re<eiptp
NEW REST DENTIAL PLMB. SQ. FT.
TOTAL:
F-' `
�>
Cioupwkingt, p Yen
bcanwith comply he surker'a Csionsm this prerea shall ha, di rated Gvoked. must
forthwith comply with such pmvisions ser this permn shell be domed revoked.
BUILDING hlili
SEISMIC FEE
Gi
CONSTRUCTION LENDING AGENCY
nW.
z
:.% 0
u" F
U
%s LLI
U Zl
1 hereby affimt that there is a construction lending agency far the Performance of
the work for which this permit is issued (Sec. 3092, Civ. CJ
Lender's Name
Lender's Addles,
1 cenify that 1 have real this application and state that the above information is
correct. l agree to comply with all city and county ordloum:esiodsw¢ laws rclmingm
bulldingconstruaton,andhercby amhoHzzmpmsen,a,ivesofthiscity winiarupon the
above.mentioned property for inspection pm,sal.
(We) agree ai use, iadcmmfy and keep harmles.v the City of Cupertino ugairra
liabilitic,judgmemeumsand expenses wMeh may in any way uccme against said City
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
ALTERORADDTOMECII.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.(100 CPM)
in cano,inarce rime gmatin, of this pcmm.
EXHAUST HOOD(W/DUCT)
PAID
Signmuic of AepImmVCmomm, Date
BEATING UNI 'T(10100,000 BIU)
HAZARDOUS MATERIALS DISCLOSURE
Deal Rcraft#
HIiATING UN11 (OVER 100,1100 BTU)
TOTAL:
\
Will the applicant or future building ammeter store or handle horrendous =led.al
as def tied by the Cupertino Mamcipal Code, Chapter 9.12, and the ]health and Safety
VENTILATION CAN (SINGLE i❑
Code. Section 25532nd, �y
Yes Y/ No
ISSUANCE DATE
nt or future buildiagpant usees,ipmeta ordeviceswhichemit
Will the applicator acu
MOILER. COMP (311P OR 00,000 BTU)
laminas air commitments as defined by the Bay Arca Air Quality Management
BOILER -COMP (OVER 100.000 BTU)
Dimricfl -v �'
❑Yes grvo
NEW RESIDENTIAL MECII. SQ. FT.
I have read the buzardous materials requirements under Chapter 695 of the
JUN 3 0 19ffl
California Health & Safay Code, Sections 25505.25533 and 25534. I understand that
If rhe building does rot currently have o tenant, that i, is 9l s sonsibility to notify fie
occupant of t wma.wl' wt be roar m una til Cc t pf
a a, 6,_ib
�IIY Ur VVrunIIPJ :i
amm
n
ISSUEDBY:��N/e-
Owncro truth trF'Ize�ugcn~
TOTAL:
OFFICE
- — I --
%