28084 t
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING.MECHANICAL 28084 O O �1
141111.DING PROJECT IDEN'1'IFICA'1'ION o v 4
BUILDINGADDRI SANITARY NO, APPLICATION SUUB�.MIT/T'A�L DATE
LI ,
OWN SNA ' ?: CON"" OR LIC NO: N • ��l
� NIC CONTROLp
ARCHITECT(ENGINEI: : LICNO: ADDRESS: ❑
COMACI': PHONE: BUILDING PERMIT INFO
Q'fY ELECTRIC VERMIS' FEE
BLDG ELP PLUMB MUCH
P MITISSOANCE �II�1TI•
I.ICENSEDCONTRACTOR'SDI?CLARATION APPL NCIS-RESIDUN'UAL )1 0 li )N ^�
p,yZ Ihereby attinn.but l am lice...wd.mder,mokionsofChnptcr 9(cnmmencing%ah
1-00 Section 7")of Division 3 of TM1e Bo.siness and Professions Cod,and mylicease is in PANELS 1 , ,
y�F
Licfullense
force nse Cls effect. l J"$ �O W
FGZ� Licenac Class Lic.g UP T0201a A. PS
m?y Dam Comra mr 201-10W AMI
Z O,ZZ ARCHTI'ECT'SDF,CLARATION OVER IIMIU AMP
OZ-0 I understand my plans shall he used as public records.
F y F SIGNS ELECIRICA
Licensed Professional
OWNER-HUILU ER OE Out Contractor's
., SPECIAL CIRCUIT'/M I\
�i0 a F hereby:dtirnt thus I am IS,
Bull'from the Crsawas is License Low for the '
oto which fiallnwinquires n permit
to 101 construct,ximxs and Professions h,or Any city orcounty TLMP.MITIiR OR POLE ST.
t vat which requires a permit To construes,alter,improve,demolish,or mpair any s.mturt
}7 prior to its issuance,also requires The applicant for such Permitto file a signed sttemen. POWER DEVICES _
Ep0 than he is llcenwd pursnam 1.he proereonsof the Commuter's IJIrrw Law(Chapter
9 Rom rating wil h Sce.ion 7000)of Di vision Sof life Bnai near i d profession,Code) SWIMMING POOL ELI?CI' C VALIIA'1'ION
W, orlhal he isexempulerefmmand she basis fertile alleged exemption.Any viol.......of OUTLETS-SWITCH" -I IXTIIRES
rya Section 7031.5byany.pplicant fur.permit subject,Theapplicammacivil penelyuf
g 0 nmmuuthan tivehundreddollarx($500). NEW RESIDE LI?L[CTR
Wa ❑ I,asownerof.M1eprnpeny,nnnycmploycexwith wages usthcirsolecompcnsasinn, QFT. E�OOD
TORIUS TYPE CONST'kUCfIDN
Y will Jothowork.andllm.truqureia nolJntendalondferW for sole(Sec]1144,❑..:nets
and I'rnfcssinns CeJr.'ITe Contractor's License Law does not apply man owner of
properly who builds er improves Thereon,and who does such work himmlf or.hrough his
own employees,provided that such improvements are notintendedoro(fined hostile.If, .GROUT' RES.UNITS
however,the hullJing or improvement is sold within one year of completion,the owner-
bnilder will have the burden of proving thm he did not hnild m Improve for purpose of
sale.).
❑ I,as ownendlhe propcnY.innesdusivelycomuc.ingwiahlicenwJ contumasm Qf . PLUMBING PERMIT FEE ZONI'. APN
construct TM1e project(Sect 7614,Hminess and Prefesxions Cwa:)The Contractor's
License Lanedoes not apply to an ownstofpropeny who builds or improves thereon,and PERMIT ISSUANCE
wbomnln.clx fur such pmjcms will,a conamen.a(x)lierawd purmlmHo she Comrnctor's
License Law, ALTER-DRAIN&VIN'T-WATER IIA) PEE SUMMARY
❑ 1 um exemq under Se<. ,B&PC for This reasonBACK FLOW PROTF.CV DEVICE TSIDE F,r
Owner pale SANITARY Y N_
. DRAINS FLOOR, CONK RECF.IPI'N
WORKMAN COMPENSATION DI?CLA Date SCHOOL TAX Y N
❑ herebyaffino Otmlhave enificaeo c� nl to selGinsurt oracenificem of RECEIITp
Workers Compemaaion luso a eii-i w,, copy lhZT ef�ce��Pre) which FIXTURES
TRAP PARK FM Y N
coscostill employees under is permit. GAS-EA.SYSTEM.I INC.4 OUTTETS RECEIITp
Policy is - BUILDING DIVISION FEES
[3 Cry OAS-EA.SYSTHM-OVHR4(P.A) PLANCIIH"XK FEE
❑ Certified copy is her yfunishcd.
❑ Cenifiedcopyi,fi, wiaif,he city inspection division. GREASR/INDUSTRL WASTH INTI?NCI:PTOR GRADING FTH
CERTIFICA -OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PER
C PENSATION INSURANCE
or les(Thixsedionnccdnol completediflic,nlitixfmo//n''e�Im 1 C. OU) SEWER-SANITARY-STORM EA.2W FT. ENERGY FEE
Ittnif,flouinlhcpinft aneeofm
Th or foh{Munit is issuW.l shall ATER IIIiATCR WNF.NI'/ELECIR
nos employ any person in t m e subject to the Workers' PAID
Grmpcnslvion I.nwx of Califom u. Dae :TATER SYS'1'1iM/1'1113M INE Dam Receipt b
C Z Applicant
Z NOTICIi TO AYI'LICANT:If,a ter making.. ' Cenifi fHxyl nn, old EW PSIUENTIAL PLMB. SQ.FT. TOTAL:
k 1-' p) become bubjecuo she Workeh mpcnsaaion Prov x uiTr e, must
fonhwi.hcomplywLM1 such pe" unser this penniTls WILt� eemnl revoked.. BUILDING FEE I�
a (� CONS'I'RU ION LENDING AGENCY SEISMIC It
Z Iherehy attinn that the abortion lending agency fe"he pedormunce..f
U O she work for which this perm:..is:sen (Sec.3097.0,C) TOTAL: ELECTRIC FEE
LenteTs Name
w0 U Lenders Address_ QT'Y. MECHANICAL PERMIT FEE PLUMBING FEE
I cenlfy shat 1 have read Ibis applie io and swm..hal then infoTmumn is
correct, I agree 10 comply with all city and arlymdinances same laws relating to PERMIT ISSUANCE MECHANICALFEE
F' h building construction,and hereby authorize re a ofthis city Toemer upon she CONSTRUCTION TAX
U Z above-mentioned pmN"for inspection purposes. ALTER OR ADDTO MECII.
(We)agre indenmlly onJ kee hnrndcxa aha CITY of Cupertino ag lm
liablli.ics, gmenu caste andexwo w may inanywuy attrucegei d ' AIR H .LNG UNITfIO IO,OIXI CIM)
me -I ence. e grand of this n.
NCLING UNIT(OVI?k 10.000 CFM)
igaan )fAWlicnnt/Co tracer Da II IAUSTIIOOD(W/DUCI')
PAID t
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNITITO 11X1,(1110 BTU) Date eeeipt Of
Will The applicenl or future building occupant store or handle hazardous material 1IHATING UNIT(OVER 103,00)BTU)
as debtors]by she Cupcnino Municipal Cale,Chapter 9.12,and the health and Safety
Code,Section 25532(a)7 VHN'HLA'1'ION PAN(SINGLE kFSID)
❑Yes Cl No „
Will:air co icarinamu a,building by the
Area Air.. uaevicesanagement
BOILER-COMPCRIPOR IFROOO RTU) f S U DA'1'Ii
hazardous air comeninans ax JefineJ by The Buy Area Air Quality Management BOILER-COMP(OVER 10(1,000 FIT Of
M
Dis'Iridl o�yal�
❑Yes 11 No - NEW RESIDENTIAL MSCI I. SQ.FT. MAY 6`e w/95
I have read The hazardous materials requiremctns under Chapter 6.95 of TM1e CITY OF GurcH I'iNU
Culifomia Health&Safe,,Code.Sections 25505, 533 and 25534. 1 understood Ihat
if the building docs not currently have a tenant,that h i,my responsibility not lily the
ecupunt of the reyaio ntents which must be mea prior Io is,uanea of o Ceniticale of
Occupancy.
Owns,or amhmrized agent Dae TOTAL: ISSUED HY;
OFF1C