28311 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
APPLICATION/PERMIT
PLUMB INf:-MEDENTI ICA n Q 311
BUILDING DIVISION xuu.urN'G PRoh:CI'JUYN'I'IPICn'ITos L o
BUILDING ADDRESS: ./ /f SANITARY NO. APPI,ICA'1']ON
suEmnTAL DATE
Zy9 pizatvs vex14SC UNIT# LOT# S94
O ,L Ii: rid , /I� Air)PHONE: '� , ACf R'S LIC NO:
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Y` N/C CONTROL Is
RCII1'113C'1'/IiNGIN131iR: LIC NO: ADDRESS: ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
Q'PY. ELECTRIC PERMIT F'EE
BLD
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f:L1:Cl' PU,IyNB MyE�C,
PERMIT ISSUANCE ITEC" �(`p5l-. _MEC
LICENSED CONTRACI OR'S UECLARA'I'ION APPLIANCES-RESIDENTIAL JOB DESCR ION
0c,Z Iherebyaffimt that l am licensed under provisiovafChapmr9(commeacmgwilh
00 Sectio 7")of Division 3 of the Business and Professions Crude,and my license is in PANELS �"��/ as �
full force and effect. UP T0200 AMPS
Q j Iy Liamc Class Lia.#
N?y Dae Cunramor 201-IOW AMPS SQ. 'T.Iq.00R AREA $/SQ.PT.
Z~O,Z ARCHITECTS DECLARATION OVER 1000 AMPS
D.Z ZA- I understand my plans shall he used as public records.
I,,,rnFW SIGNS ELECTRICAL
65X7_1] I,iccnncJ Profcnsiowl
rzx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
X0noU 1 hereby affirm that I am exempt form the Contmnu/s License Law for the
Ui fallowingreason.(Section]0315,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Eholwhich acquires a permit to construct,alter,improve,demolish or repair any stricture
5 }5. prior to its issuance.also requires IM1e applicant for such permitm fileasigned malemem POWER DEVICES
y�jC�O that he is licensed pursuant ro the provisions of the Connector's License Law(Chapter SWIMMING POOL ELECTRIC l4 E: 9(commencing with Section 700(4 of Of vision 3 of the Business and Professions Code) VALUATION
or that he is exempt therefrom and the basis for alleged exemption.Anyvi.hoomof
m
,ZQ mol Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of OUTLETS-SWITCHES-FIXTURES
more, f vc hundred dollars($5001.
c O rc him NEw RESIDLNt'1AI.ELECIR _SQ.IeII 5'I'ORIIiS '1'VI'I3 CONSTRUCTION
W' :. ❑ I,mownertftheprnpenY.ormyrmployaswilM1 wagesavheirsolecompensation.
a3e= will do the work,andthe swcture is not imendedoroffercd for sate(Sce.'/Oaq Business
and Profession.,Cad,'Bw Contmemrs Littmso Law does nor apply in an owner of
property whobuilds or improves lhercan,and whodoes such work himselforthroughhis
wnemployees.provided datsuch improvements anotinmmdedoroffered formic.If. OCC GROUP RES.UNITS
rt
however,IM1e building or improvement is sold within one yearofcompledion,the owner- ±45!
�•
builder will have he burden of proving that he did nm build on improve for purpose of
fie')' QTY. PLUMBING PERMIT' FEE II.ODD LONG APN
[:1 Las owner ofthe property,umexclusively contracting with licensed contractors to
onswm the project(Sea 7044,Bu,mrss and Professions Codc)'I'bc Convect x
Lianselswdoes nor apply roan ownerofpmpeny whobuildsorimproves Nercnn,arta PERMIT ISSUANCE.
whoatmmets for such projects with a commensals)icensed pursuant home Contractor's
License I,awALTER-DRAIN&VP,NT-WATIiR(EA) FE $U ARY
.
❑ I am exempt under Sa. .B&P C for Ibis mann BACK FLOW PROTRCT.DEVICE Call'ISIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,ARE .CON RECEIPT'#
WORKMAN COMPENSATION DLCLARAI'ION SCHOOLTAX Y
❑ Thereby affirm thmlhave ecenifi<menfconsmno self-insure,meartifcem of # IIXTURIS RECEIPT'#
-PER TRAP
WorkersCompensation Insurance or scenifed copy lhereff(Sce.3800.LabC.)which PARK FEE Y N
coverx all employKs under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
BUIL TNG DIV]]]]
policy FEES \
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEB. \
❑ Certified copy is hereby famished.
❑ Cenificd copy is filed wilM1 IM1e city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRAVING FE \
C17RI'IIICATE OF EXEMPTION FROM WORKERS' GREASE'I'RAP SOILS
COMPENSATION INSURANCE
(This union nod not becomplead iflhe permit is for one hundred dollars($IW) SEWER-SANITARY-STORM EA.200FT. INI?RGY
or less.)
I cxnify that in the performance ofthe work for which this Permit is issued,I diall WATER BEATER W/VEN'DELEC1'R /
nm employ any parson in any manner so as m become subject m the Workers PAID
zCompen,allnn Lawsof Culifomia. Data WATER SYSTEWREATING Data eipr
O Applicant
NOTICETO APPLICANifca
T:If,after making this Cane of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TO'1'A
t2w Vn
J became subject the Worker's Compensation provision of be Labor Cade,you must
forthwith comply with such provr%ims or this permit shall be deemed revoked. BUILDING FEE
[� CONSTRUCION LENDING AGENCY SEISMIC FEE
Z 1 hereby afford 0m 0cre is a construction lending agency for IM1e performance of ELECTRIC FEE
U U the work for which Ihis Permit is issued(Sec.3091,Civ.C.)
Lender's Name
PLUMBINGFEE
0 F i,anhos Address QTY. MECHANICALPERMIT FEE
U 1 verify that I have read this application and stale that the above infommoon is MECHANICAL FEE correct.I agree to comply with all city and county ordinances andsmm laws relmingto PERMIT ISSUANCE
(~ builAing n,nurudion,and M1crcby umharirc rcprcsenunivea of lhisciry memvr upon the CONSTRUC IONTAX
U Z above mentioned progeny for inspection purposes. ALTER OR ADD'1'O MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilhics,,adgmenls.enslsand expenses which nayinany way accrue against said City AI R HANDLING UNIT IT Io.000 CFM) �s
xqu cc of IM1e granting of this profit. 244,/11
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanVCnmmnor Data EXUAU ST I IOOD(WMUCG) PAID
HALARDOU. MXHzRIALS DISCLOSURE ItIi TING UNIT(TO 100,100 BTU) Date RaeiprN
win he applicant or future building occupant store or handle ha,ardou.,material
as defined by the Cupertino Municipal Care.Chapter 9.12,and IM1e Health and Safely HEATING ON]((OVER 100,100 BTU)
Cade,Section 25532m)? VENTILATION PAN(SINGLE RESID)
❑Vas ❑No
BOILER-COMP(3HPOR IW,f1W tli U) ISSUANCE IME
Will the applicanmr future buildingoccupant use equipmemit ntordeviceswhiche
hazardous fir contaminants as defined by the Buy Amo Air Quality Management BOILER-COMP(OVER 100,0(10 BTU) ALJ
Dismal?
❑Yes 0 N NEW RESIDENTIAL MECII. SQ.FT.
1 have read the homajous materials rcquncmcnis under Chapter 6.95 of the Cpy 6 08 199
California Dean&Safety Code.Suctions 25505,25533 and 25534.1 nMerslaad in., to (�
if rbc building does am curemly have a heron,that it is my responsibility to ratify the
eecapanl of life requirements which mast he met prior m isxaaa a of a Cenlfionr of ^
Occupancy.
Outa—amhnrized!got Data T( ISSUED BY:
OFFICE
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