28029 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BlmnrnG.F.I: cTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDEN'I IF'ICA'I[ON 28029
BUILDING ADDRESS: SANITARY NO. AP/PLICATION SUBMITTALDAM
,2079/ GO 2 / I r UNIT# I.DI'N
OWN17RS NAME: Lf, ff PHONE: CON TRACTORS NAME: LIC NO: l
'elQ reGK j '— O N!C CONTROL#
• ARCHITECfENG1NEER: LIC NO: AD ESS ❑
CONTACT: PHONE: t a 1 a't Bd) - }, BUILDING PERMIT INFO
as7 s—d j :,:Lt x •�r * + EIPGIRIC,PERMIT . - FEE
J L! �2 rn bYO ck :R d S).W EY.i:' t .t1 - -BLDG ELECT PLUMB ME H
J PERMIT ISSUANCE {�7�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
0mz Ihereby affirm that lam licence)mnderprovininnaof Chepter9(commenting with JOB HSCRIPI'ION
WOO Section TJflo)of Division 3 of the Business and Professions Code,and my license is in PANP n
fall force and effect
La.,Zw License Class Lic.# UPTO200AMPS
rn,a>y Date Connector 201-EX0 AMPS
z8nK ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FP.FLOOR AREA VSQ.FT.
O Z_a 1 understand my plans shall be load as public records.
rn SIGNS ELECTRICAL
Licensed l'roleosional 6 OWNER-BUILDER DECLARATION SPECIALCMCUU/MISC.
OaF 1 hereby affirm that 1 and,exempt from the Commctors License Law for the
LL O y following mason.(Section 7(131.5,13usineos and Professions Cade:Any city or county TEMP.METER OR POLE INST.
ron which requires a peanut to construct,eine,improve,demolish,or repair any structure
WYg prior to its issuance,also requires the applicant for such permit m file a signed statement POWER DEVICES
0.0.''a than he is licensed pursuanT1.Ne provisions of the Contractors License Law(Chapter
0. OC 9(commencin with Section 7000)of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
Woµ, B ) VALUATION
WL, Srthat
lon 7031.5 by thandou,applimand the permit for exceigeJeaemption.Any m.civviolm,,d` OUTLETS-SWITCHES-FIXTURES
FZQ Section 1031.5bywydineddentforapermit sobjensthe applicant to ecivil penally of (�
O �.ral1{morathan five hundred dollars(E500). NEW RESIDENTIAL F.LECIR _SQ,FT.
tY o gL Lns uwncrophepralnny,mmycmployeeswithwages as Ncirxolecompensntion, STORIES TYPH CONSTRUCTION
a300 Jlldmhe work,and the srmcmreisnot inandedor Mfned forsele(Sec.J614,Business
and Professions Coda The Commcarts License law does not apply to an owner of
prepeny who builds or improves theroma and who Dees such work himself or through his
own employees,providedrhar such improvements srenotintendcdoro(fend formle.If. OCC.GROUP RIS.DEL IS
however,the building or improvement is sold within one year ofcomplerion,the owner.
builder will have the burden of n that he did nor build or int for TOTAL:
provi g prove purpose of
sale.). -'
❑ I,as owncrnfthe n y contracting Qtw PLUMBING QEF, x FLOOD ZONE. APN
property, Business,
a Professions
with Th enntmarorsr's h A r,�
construct the project(Sec,rose,Business pe Professions Code:)The Contractor's
License
Licensemen,for sec applytowoh a conpmpenywhosed Journ improves thereon,and PIiRMIT ISSUANCE
who acumen,for such projectswitheconvunor(s)IicenuJ pursuuntmWe Convenor's ALTER P
Liccnx law. (-A) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUT :S
SANITARY YN
Owner Date• DRAINS-FLOOR.ROOF,AREA,COND. RF.CF.IPrf,e WORK MAN COMPENSATION DECLARATION SCHOOLTAX V N
El Ihereby affirmthat l have acertificmenn
eofconso self-insore,oro monficateof RECEIPT It FIXTURES-PER TRAP
Workers Compensation Insurance nrvicenificd copy thereof(Sm. Lab C.)which PARK FEE YN_
over,all employee's under this penmh' GAS-LA,SYST'FM.1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifed copy is hereby fumixhed.
❑ Carolled copy is filed with the city inspection division. GREASHANDUSTRL WAS 1
GRADING FIiE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE.
(This section need not becomplemd lfthe permit is for one hundred dollars(E100) SEWER-SANITARY-STORMF .200F1'. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this permit is issued,I shall WATER HEATER WN .LECTR
not employ any Person in any manner on v to become subject to the Workers' PAID
Cnmperamtian laws of CNifmmin. Date WATER SYS TING Dore Receiptp
O z Applicant
z O NO LICE TO APPLICANT:IL after making this Certificate of Exemption,you should N13WRESH` LMB. r, SQ.FE TOTAL:
rV) become subject to the Worker's Compensation provisions of the labor Code,you must
a ; forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
W z EN
CONSTRUCTION LENDING AGENCY SEISMIC FEE - v
^� Ilmrcby nffum than them is.construction lending agency for the perfmadempeof
U O the work for which this permit is ismad(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
V. r Lender's Name r
C' lender's Address p'I'Y: L : MECIIANICALPERMIT""` 'FEE
PLUMBING FEE
V I cenify,Nat 1 have reed this application and sure char the above information is
corm". I agree to comply with all city and county ordinances andomre lavandoid,to PERMIT ISSUANCE MECI IANICAL FEE
F' y building conswclion,and hereby amhons,representatives ofthis city roomier upon the
U above-memioned propmy for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)vgree to save,indemnify and keep harmless the City of Cupertino ag.lost
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
n 9uence of the graming of this permit.
AIR HANDLING UNIT(OVER I0,000 CFM)
S' [sere afA ¢unpCommcmr Dete EXHAUST HOOD(W/DUCO
PAID ` t#
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,000 NTD) ' Oa te Receipt M f,
Will the applicant or future building occupant sane or handle Instructions mmenal
as HEATING UNIT(OVEN 100,01M BTU) 'LOYAL: ff^
defined by the Cmarino Municipal Cale.Chapter 9.12,and the Health and Safety
Cade,Samoan 25532(v)?
11 Yes CI No VENTILATION PAN(SINGLE RESID)
Will the applicant or future building necupnm use equipment art devices which emir
BOILER-COMP(3HP OR 100,00p BTU) ISSUANCE DATE
hazardous air conmminants as defined by the Bay Area Air Quality Management BOILER 100,009 BTU)
• District? P A 1 D
❑Yes ❑No NEW RESIDENTIAL MECO—SQ.FT.
I have read the b tworg o,materiels requirements under Chapter,6.95 Oddie JUN 01 1995
California Health&Safety Code,Sections 25505,25533 and 25534. I undcrsrand dant
if the building does not curready have a tenant,that it is my responsibility to notify the
occupant of the requirements which must l e met prior to issuance of a Cerificam of /s II� s „
Occupancy. C Y lJf r y O.rr/JFK/(JA
Owner or aanleeired agent Dae TOTAL: ISSUED BY'
OFFICE