25486e
cmZ
FOO
a�
6
N5y
F
O7,44
OZ -0
245
X ie FU
W "co
�tNuy��J
Ia�i5 q0
4 0�
uxi _.ti
W w
0.
RDDI If J1NT TO FIf LIN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILUINf. RLEC'1'RICAL
CITY OF CUPERTINO PC NO
BUILDING DIVISION APPLICATION/PERMIT
. �; IIWLUINQ PROJECT IDF.NTIFICATION�•
PERMIT NO,
n C /I O �..
L J 4 0
BUILDING ADDRESS: s /'7
UNIT# LOT Ir
SANITARY NO.
��
APPLICATION SUBMITTAL OAT
�Vv/
OWNERS NAME: PHONE:
CONTRACTSp:gN 2, C ICN
IIPOCaD
NIC
CONTROL#
ARCl11TECT/ENG1INEEI -� LIC NO:
tj"; V
CONTACT: faO PHONE:
4 840V1
° K �-• -
E
BUILDING PERMIT INFOCE
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT 'S DECLARATION
1 hereby aff mr that I am licensed under provisions rf Chapter 9 (commencing with
APPLIANCES - RESIDENTIAL.
LOB DESCRIPTION
Section 9000) of Division 3 of the Business and Professions Code, and my license is in
full force ndefPofl.
Licensense ClClass Lia#
PANELS
UP T0200 AMPS
201 - LBBB AMPS
Date Cionommr
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER IOW AMPS
SQ. PT. FLOOR AREA
(�
/_I r ^ II
$/SQ. PT.
SIGNS ELECTRICAL/
\ L" 101 \tl,
1 ^ rr p�
I�.rI•I {: R
Llcenead Profaeslonal
OWNER-BUILDERman
SPECIAL CIRCUIT/MISC.
bv6ARATION
License Law for themy
I hereby affirm that I am exempt fnnn the Contractors Cock:
followingquires a(Section]0315, Business Professions Ca de: Any city or county
Ill 01."✓
y
17i�
TEMP. METER OR POLF:INST.
which
which requires issuance, permit re consweL aper, improve, demolish, fi repair any structure
pr
lsl the applicantnsofor ch to ant
/ Ghl/
POWER DEVICES
tprior hat he LieeseLw(Chgned
censedpursuant to the the Contractor License Lew (shaper
the he is licensed pursuant to the provisions of the Ce Business and Professions Coda)
Divibasis
3oPpraed
9( cat ixewithefonn7") ofit
SWIMMING POOL ELECTRIC
VALUAT
he is exemption.
Se that he is exempt therefrom and the basis for the alleged exemption. Any violation of
by the applicant mncivil penalty of
OUTLETS - SWITCHES - FIXTURES
sPermitsuhjeas
not mom than Floehundred dollors($50
❑ 1,asownernftheproprty,ormyemployeswithwegesnstheirsolecmpensatio,
NEW RESIDENTIAL ELECTR SQ. FT.
STORIES
l'YPE CONSIftUCI'ION
will do the work, andthosty amrels but lnteadedoraffered for sale (See. 7144, Buslnass
and professions Code: The Contractors License Law does not apply to an owner of
property who hui Ws or improves thereon, end who does such work himself m through his
employees,provided that such improvements arenof imendedond'fered forsole. If,
OCC. GROUP
R85. UNITS
TOTAL:
however, illhar ldingorimprovement le soldwithinone t build of c prove on,for the ower-
sold it
builder will hove the burden nrproving ohot M1c did not build or improve for purpose of
QTY. r .'PLUMBING PERMIT r FBA
ry e
sand.).-"
1:1I, as ownemFlhe prolxrty,amexclusively wnvacting with licensed commas r r
onsoum the project (Sec. 7044, Rosiness and Professions Cale) The Contractors
IJcense Lnwdoos pplymnnownemfprnpertywhosedpurs improves
FLOODZONE
ANN
I
PERMIT ISSUANCE
suchContra,and
who oonhansfor such projects with a wouamoge) licensed pursuant m 0e Contmcmr's
License Law.
ALTER - DRAIN&VENT - WATER (EA)
PEE SUMMARY"
E] 1 nm exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT, DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherehy affirm thmlheveecertificete of consent to sel6insure, oracenifice¢of
Workers'Compensation lnamence aacertiful copy thereof(Sec. 3800, Lub CJ which
corals all employee's under this permit.
Policy #
RECEIPT#
FIXTURES - PER TRAP
PARKFEE Y N
RECFIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furromed.
GREASRINDUSTRL WASTE INTERCEPPOR
GRADING FEE
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Thisseenam reamer he completed lfthe permit is for one hundred dollars($100)
or less.)
WATER HEATER WNENT/ELECfR
I samiyflst in the pefifermenceofthe work For which this permit is issued, l shall
not employ any persun in any manner sn as to become subject or the Workers
PAID
Compensation Laws of Calif rand, Dam
WATER SYSTGMOREATING
Date Receipt
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FE
TOTAL:
become subject o the Workers Compensation provisions of the Labor Code, you must
Forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a,mrtmction lending agency for the performance of
Edworkfor whichrhis permit k notied(Sce. 3097, Civ. CJ
-
TOTAL:
ELECTRIC FEE
Lenders Name
Lenders Address
6 • a - - x - .} a # 5 ,. ,
- e .�CMANHCAL PERMTT t #FEE' d •
QTY. -tMA
PLUMBING FEE _
1 oedify that 1 have tend this application and state that the above Information is
lea. legrce to comply with all city and county ordinances and sem laws relating to
` " " " " " -
PERMIT ISSUANCE.,
MECHANICAL FEE
building construction, and hereby authorize representatives of this oily to enterupun Ne
above-mentioned property for inspection purposes.
ALTER OR ADD TO SUCH.
CONSTRUCTION TAX
(We) agree 1. sare .'ademniI, and keep hoass the City of Cupertino against
'Isaliabilides,judgsswhich nyi any way accrue against said City
AIR I IANDLING UNIT (TO 10,000 CPM)
in conseque min ext E reit.
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD(WNUC)
Signature o'ApplicanVConwcmr Date
pAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dole Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the IEarth and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Cade, Section 25532(a)9
11 Yes ID No
ISSUANCE DATE
Will theapplicnmorfmurehuilding recapantuxeequipment ordevieds wbichemlt
BOILER- COMP CHIP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management
,District"
Sy '
p
NEW RESIDENTIAL MECH. SQ. FT.
ElP
Y's ❑ No
#'1 D
1 have read the hazardous materials requirements under Chapter 6.95 of the
p
"•V�
Califomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
Ocup our of the requirement; which must be met prior to Issuance or o Certificate of
ccupancy.
YYy 41
�% Ur, 93
VV
ISSUED BY:
Owner or authorized agent - Date
TOTAL: