28312 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 28312
BUILDING PROJRC'T IDEN'TIF'ICATION
BUILDING ADpR' S: SANITARY NO. APPLICATION
LICATION SUBMI I'1'AL DA'Hi
Z L 1q 4�� f
LO f# V�9_�q�
OWNS E: PHONE: CONTRASI'OR'S NAME: LIC NO:
mvii, is / e,y7 1 rI O /s O [` C �f N/C CONI'ROLq
\RGIII'TECT/IZN dNF,ER: �.F�>rT LIC NO. Leis
O l•� S J C��1/2
gig
CONTACT: PHONE: BUILDING VE MIT INFO
QTY. ELECTRIC PERMIT PCF.
k'12— BLDG ELE PLU MECII
PERA11'1'ISSUANCE
LICENSEDCONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
thereby flim that l no licensed under fCa I 9(commencing with JOB DISCRI ION
O tYZ Ihyn provisumso per
WdbSocfull for ,andef ct.1 onJof me Business and ProfessinnsCWc,and my license is in PANELS
y<F full(trate and effec—I"
FZtn License I s Lic.W UP TO 200 AMPS
ns6vR'i Duro Convector 201-IWOAMPS
ZO„z ARCHITECTSUECLANA'TEON OVER100DAMEIS Q FI' FLOOR AREA $/SQ.FT.
OZ-0_ 1 undcrsmnJ my plans shall be used as public records.
rm��.II Licensed Professional SIGNS ELECTRICAL
�f aa< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�Op�,U I hereby affirm that I am exempt from the Contractor's License Law for the
Ina ay following mason.ISomm 91131.5,Business and Pre(cssions CWe:Any city ar county THAT.METER OR POLE INST.
C< which matrices a permit it,consumer,alter,improve,demolish,or repair any strucmm
�1�1YY}� prior to its issuance,also inquires the applicant for such permit m rile a signed statement POWER DEVICES
µ�jK�p that he is licensed pursuant o the provisions of the Connacmr's License Law(Chapter
u-n%.o� (commencing with Section of Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
W_rn orthat he7031. by yapplimand the Permit sbjeesegedexemprt to civiny l] natty of OUTLETS-SWITCHES-FIXTURES �—
[-. G Section ID3lSvea undredicant(or$500).tsubjects the applicant macivil penalty of
W not moreowthan livetheprod Janusyomp.
K m ❑ I,asownerofineprapeny,ormyemployeeswithwegesmthcirsolecompensetion, NEW RESIDENTIAL RECTR _SQ.FT. STORIES TYPE CONSTRUCTION
43— will dome wmk,and thenmalma is not i eandedaraffered inside(Sao 701,,Business
and Professions Code:The Comracmr's License Low does not apply to an owner of
property who bulldsorimprovestherenn,and whodoes such work himsalformmughhis OCC.GROUP RES.UNIT'S
own employees,provided that such improvements am nm intended or offered for sale.If,
however,the buildingor improvement is sold within oneyearofcompletion,the owacr- TOTAL:
huilder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ Las owner oflhe property,am exclusivelycontracting with licensed enmfnemrsm QTY, "PI UMB F:RMIT FEE FLOOD LONE AI'N
construct the project(See.704,,Business and professions Code:)The Conummra PERMITISSUAN
Licenu Law doesnotapplyto anowncrofProperty,whobailds or improves thereon,and
IN
who oonvems for such projects will,scrmrenrgs)licensed prostration the Contractor's ALTER-DRAIN&V. '1'-WAT (IA a
License Law. ) PCL SUMMARY
❑ 1 am exempt under Scc. ,B&P C for this reason BACK FLOW PROTECT.D LCE T91DF.FEE
SANITARY YN
Owrcr Date ECELPTp
DRAINS-PLOOR.ROOI',ARPA, ONI
WORKMAN COMPENSATION DECLARATION SCHOOLTA% N
❑ ors-Cmlematthatlheveacmificaleede. emmsdginsum,ar LahC)).hichcale of 1`107URFS-PER'TRAP NE N
Work1 covers all
amployeas nWtrmaarmit. ifiedcnpy thereof(Sec.3800,Lah CJ which PARK FEE N
covers ullemployeds under t. [ >IPTp
permit. GAS-fA.SYSTEM-I INC.,OUTLETS
Pricyk BW&GINd 4fVISION FEES
Company❑ CeniRedcopyishembyfumished. GAS-FA.SVS)EM-OVPR4(EA) PLANCHECK c'
❑ Certified copy is filed with the city inspection division. GRIASEANDUSTRL WASTE INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASETRAP SOILS FE
COMPENSATION INSURANCE
Mis section need not he completed ifthe permit is forma hunmeddollox(SUM) SEWER-SANITARY-STORM EA.2001Ff. ENERGY FIFE
or less
I certify that in the performance adds,work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
aot employ any person in any manner sot as ty pcy �s to the Workers' PAID
Campensntion Law Pyo: ry/ T� � WATER SYS)EM(fREATING Date Rece tp
NOT'ICE TO APPLICANT:If term i his Certificate of Exemption,you should NIiW RESIDEiNTIAL PLMO. SQ.Fri. 'll)'AL:
� Become subject to me Worker's Compensation provisions of the Labor Ce.you must
a > forthwith comply with such provisions or this permit shall he damned revoked. I BI It.
0.Wi Q CONSTRUCTION LENDING AGENCY SEISMIC ME
7 z I herebyaffirm shot be.is a construction lendmit.,uney for the perfnrmanceof
U O the worth for which this permit is iswed(Sce.3092,Co.C.) TOTAL: ELECTRIC FEE
V. ti
Lenders Name PLUMBING PEE.
I ce
F Lena ci Murcia Q'Y. ,MECHANICAL PERMIT - - PCE
L) rtify that I have read Nie application and sous that the above information to
building
construction,
and with
yautcity and representatives
ntativ softhid state enter uaungm PI?RhfIT ISSUANCE MECHANICAL FEE
F-' z tilawongmnaradIrmied to,nexpe,l!.izempmsenurives ofthis city to enter upomhe CONSTRUCTION A%
U nhnvo-mentionwlpmponyfminspy ad purposes ALTER OR ADD TO MECII.
(We)ogres n servo,indemnify and keep mayor
the City of acme
against
liabilities,judgnounts,ttrs¢and expense))wM1icM1 may in vhyway occrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
).nn.,,f the renin o tabs it.
/ ID/s” � AIR HANDLING UNIT(OVER 10,0!1(1 CFM)
Signature of Applica ontmct r Data EXIIAUSTHOOD(W/DUCF) PAID
ALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Data Raeipt p
Will the applicant or future building occupant.store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING ON It'(OVER 1011,000 BTI!)
Code.Senior 25532fe)1
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
OISSUANCC DATE
Will he rapplicantorfrmre building occupant use equipment mdevices whicherch BOILER-COMP(311POR UEOtl BTIJ) n s
&SIDisevcontaminantsous air contaminants as defined by the Pay Arm Air Quality Management BOIL ER-COMP(OVER U))JXX)BTU)
❑Yes ❑No NEW RESIDENT1ALMECII. SQ.Fr. IQsG Tr` ]^
I have read the hazardous materials requirements under Chapter 6.95 of the �/� I
California Health&Safety Code,Sections 25505,25533 and 255U. 1 understand that (` +
il'the buildingdoesoat currently have a tenant,thin it is myrespmnialit".inailyffic X1/1
rcemert of lie requirements which roust he mel,prior 1.issuance of a Ceniticak of /bL
Occupancy.
Donator amhorized agent Data TOTAL: ISSUED BY:
OFFICE