28062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD,door-ELECTRICAL. PERMIT NO. 2 O O V Z
APPLICATION/PERMIT PLUMBING-MECHANICAL. L o
It
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /l / UNITN LOl'M SANITARY NO. APPLICATION SUBMI ITAL DA'11;
OWNERS NAME: Ka GIPHONE CONTRACTORS NAME: VIC LIC NO: CONTROLM�
6 NIC3
RCHITECryENGINEER: LIC NO: ADDRESS: _. F-1-12 6 &1 05e/% Q t Sv u
et
CONTACT: PHONE:
QI �s QTY. ELECTRIC PERMIT FEE EUILDING PERMIT INFO
'*,V 3b,f-/66a BLDG ELECT PLUMB MECH
PERMIT ISSUANCE .2"" ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm that l am Recruited under provisionsof Chap¢r9(commencing with Cti Me
X00 S«lion]WO)ofDivieinn3nf the Buainuvv and Pndesninm Cnde.unJ my license iv in PANELS
ZLcenx Clnd Lic.M GL3309 UPT0200AMPS ��0� /I -/!
w=y Dare i, Canlrecmr a./.,�.�(�lK� 201-IIXNIAMPS SQ.IT.FLOOR AREA f•• _ v� .FT.
zoy— A CHITECI'S DE 'ITC�y'r -a OVER 100TAMPS
OZ-5I] I understand my plans shall be used as public records.
mA; SIGNS ELECTRICAL.
GJ Licensed lkolessional
❑�W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOaF I hereby affimr mm 1 em exempt from the Camrvemts Littnx Lew for the
ad�+ay following reavnm(Seelion101IS,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
v4deh«gaires o perail In construct,aher,improve,demolish.or repairany structure
primidil.sissasale.alnn:eyuires the applicant forsuch permit to filersignedatatemenl POWIiR DEVICES
m��p that he is licensed.ursaaa,r+he prwWorsof the Caniradnr's License Law(Chapter SWIMMING POOL ELECTRIC
aao� 9(commendng witb S«linn]00o)of Division 3oflhe Guiness and Profession,Code) VALUATION
,MZ .,,he,he is excmpuhemfrom and the basis for me alleged exemption.Any sudittianof OUTLEL'S-SWITCHPS O O
GSection 0031.5 by any applicant for a permit subjects the applicant m a civil Penalty of FIXTURES
not mato man Ove hounino dollars(9510).
ro ❑ Lnsownerofthepropany,ormyemployeeswithwagesastheirsole compensator. NEW RESIDENTIAL ELECTR _S STORIES TYPE CONSTRUCTION
per, will do the work,and the structure isnot inlerded oroffered forsale(S«.'10,1,Business
and Professions Cade:The Committees Licerese law does OOI apply to an owner of
property whobuildsnr comovcsmer«nand whodms such workhimeelfarlhroaghhis
own employees,provided that such improvements=not intnadedaroffered Tarsale.If. OCC.GROUP RL'S.UNITS
however,the building nr Improvement iv sold within oneyear ofurmplcllnn,Ihwwner 9'0'PAI
builder will have the burden of proving that he did not build or improve for Purpose of
sale.). QTY, PLUMBING PERMIT FEE DD ZONE APN
i
❑ I,es owner project
(Snpeny, .Business
Professions
licensed Contractor's
Licenseslhe project(Sec.0Ba4,Buridju and Professions Cod J'Me Coraeator's
License ants far with.
igrplyldenowneroflnopeny who huildsmimproves the themusonland PERMIT ISSUANCE
whence Liole far such protects wilheconaucmr(e)IicenseJ pursuonuolhaGmwctor'e ALTER LA
� License Low. (' > FEE SUMMARY
❑ I um exempt under See. —� P C for this on BACK FLOW PROTECT.DEVICE ES
ITARY O Y D:IN
Owner Date DRAWS-FLOOR.ROOF,AREA,CONI(. RECE1P`P#
GERMAN COMPHNSATION DECLARATION 'IC40 T Y N
❑ ILembyaf n lhullllaveacenificamofconsenitosclf-insure,orattrtificate FIXTURES-PER TRAP RECEIPT#
Workers'Co., ¢lion Insurance aro raffievi copylherco00
pSec.38 ,Lou C.)whit PA FE Y N
coversell employ ' ilORnlll' R GAS-ITA.SYSTEMA LNC.40UTLLTS RECEIPT.
PolicyM // BUILDING DIVISION('EES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK PER 00
[I
aced.
❑ CertifedeV isfi dwiththe cilyinaopecuon�lp(/R. tun. GREASI➢1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CE 'C E EGPt10A"I%obI .LRS' GREASETRAP SOILS FEE
O ENS TION INSURANCE
(TTlssu:to need nM1e complmulifthepermit is foronehund dolLu ) SEWER-SANITARY-S'I'ORM EA.2WFf. ENERGY FEE
or lease.) �
I ttnify mm a the perfnormad^e of ewnikf w chi ' it is ssu .(shell WATER((EATER WNIiNT/ELECTR
not empioY anY non m any moon a1� ubj«t b Ise orkers' PAID
Compensation) sof California. ale WATER SYSTEM(IREATING Data Receipt#
0 z Applicnm
Z NOTICI3TO AP LICANT:IL ufmnnuking this Cedilicutc of P.xemptian,you should NEW HESIDENTIAh PL,MB. SQ.FT. TOTAL.
F sem. M1ecomc mbjecn the
Wnrker''C
Comnsation provisions of the Labor Cnde,you muss
> forthwith comp) wish such provisions or this permit shall be deemed revoked. BUILDING ITE I
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
rrCrr Ihereby in ohm Thera is a construction lending agency for the performanceor
V O Ihe work for whie (his parmlt iv issued(Sec.3099.Crv.C.) TOTAL: ELECTRIC Plili
Lenders Namc PLUMBING ITE
Lenders Address QTY. . MECHANICAL PERMIT FIEF.
V L certify that I hu ad Iris appj¢atiomvrtd store Item be above information is
rnerca. lugrce mcomplywitha it's. county ordinances and state lows mlatingm PERMIT ISSUANCE MECHANICAL I'EF.
Q' building emi,ruetion,rod hereby authmimrepresenlmives of this city m enter uponthe CONSTRUCTION TAX
U �
U "� abnv(Wentiancd property I Tad purposes, ALTER OR ADD TOMECtI.
(We)agree on save,indemnify and keep h less the City of a ri'm ro id Cit l
Ilabililin,j nls,comsu swhi yinunywayaccme against said City ALR HANDLING UNIT(TO IO,Otq CPM)
In Caa9e CrIC II IIIC gra n e% 19 py
AIR HANDLING UNIT(OVER 10J00 CFM(
Si urco pp 'ontm Data EXHAUST HOOD OMMUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTI) Data R«eiptg
W ill the applicant or future building occupant store or handle hazardous material
as defined by the Qrpaninn Mrmiolpal Code,Chapter 9.12,and the IJoa11 h and Surely HEAT(NO UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)'1
1:1 Ycs ❑No VEN9'ILATLON FAN(SINGLE RESID)
BOILER.COMP(3HPOR 100,00i ISSUANCE.DATE
Will the applicanmrfuwrebuilding occupant use eyuipmcnlordeviceswbichemil p'� p R
hazhazardous air contaminants u defined by the Bay Area Air Quality Mamrgement BOILEk.COMP(OVER 100t,1 .000 BTU) T /1 LY
rido
El Yes E)No NEW RESIDENTIAL MECIL SQ.FT. �Il Q .I^aA�
I have read the hazardous materials rcquiremomA`. V s under Chapter 6.95 of the 99
California I Leah,&Safely Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not comemly have alemmn,that aixdry responsibi lily to anufythe CIIY UE I.,urtn'I OU
cupanl of the requirements which mum in met prior u+issuance of a Certificate of
Occupancy.
Owner ar authorized agent Date TOTAL: ISSUED BY—A1
OFFICE