28392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 'LJ L
BUILDING DIVISION BUILDING PROJECT IDENTIFICA]'ION
BUILDING ADDRESS: ,^ SANITARY NO. APPLICATION SUBMITTAL DATE
2011' AA�-S ,E $ vD2JE UNIT# LOT#
O�RSNAME: PH�uF: CO,
O ACTOR'sKNAME: LIC NO:
1CosE 'MA _% I— IA P'eJ I�fZy,� lj�lxJQpo,�,5 \.SC , N{c corrrRol.x
ANCIII'IEC17FNGINEER: LIC NO: ADDRESS.7LZ Al,A S I N`3 t SA-1 El
CONTACT: per,.\DQjFb JJ Qxi?tHON,�E: QTY. ELECTRIC PERMIT rFEE
D w RUILDING PERMIT INFO
QL "'__'S CQ ks� ?4t —�Z�I PERMIT ISSUANCE RLIx'i ELECT 1'El MECH
32. 1�, ❑ ❑
LICENSED CONTRACTORS DECLARATION APPhIANCIiS-RIiSID[NTIAI. JOB DESCRIPTION
py.7. thereby of
fDithio am licenseduunder provlslfesions Corte,and mmtnense with
at W Seaton r mad v f Division 3 of the Business and Professions Code.and my license is in PANELS
aUt rrmntroeamleBe.� Az2.3o
QZm License Class Lic.M UPT0200AMPS v^�
mQc- Date ) Contractor t� 201-1000 AMPS
f'-'z ARCHITECTS 11 CLARATIO, gJJwkan,A Sr OVER I�XI(1 AMPS SQ.FT.FLUOR AREA
Zoos— lundersandm 1
OZ^D Ypuns shall be used us puM1lic readds. A:
P=w %A:
SIGNS ELECTRICAL
a Licensed Professional
CCyQ OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
OyF 1 hereby affirm that I um exempt from the Contractor's License Law for the
tL3ati following reason,(Section 9031.5.Business and Processions Cade:Any city or county TEMP.METER OR POLE INST.
k��,¢j which rcquircsupttmir mconswet,after.improve.Demolish,or repair any structurepOWF,R DEVICES
C.Y2 prior to is issuance.also re rams the applicant for such penni to file a signed statement
tvzm0 that he is licensed pursuant to the provisions of the Commcmrs License Law(Chapter SWIMMING POOL ELECTRIC a Z: 9(commencing with Section]01 or Division 3 of the Business and Professions Code) VALUATION
WMm or that he is exempt herefrom and the basis for alleged exemption.Any violation of OUTLETS WITCHES- /s M
F%¢ Section 7031.S by any applicant for a permit subjects the applicant to a civil penaltyf 5 FIXTURES vV �lYl x ��
5 O not mom than Eve hundred dollars($500). �/lJ
a El1.:uowneroftheprnperty,ormyemplmyeeswithwagesastheinal¢compensation, NLW RESIDI3NTIALELECfR _SQ.FL STORIES TYPE CONSTRUCDON
y3— will do the work.and the structure is not ineadMaroffcal forsale(Sec.](W,Business
and Process ons Cnde:The Contractor's License Law does not apply to an owner of
propery wbabuildsar impraves therein,and whadoes suchv arkhi re eBor through his
own employees,provided that suchimprovcmcnts are not intendedornrf'red fasale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold withmone yearofeemplethe.the owner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,asownerofthepropeny.omexchusivelycontmcoing with liecusedommacmrsro QTY. PLUMBING MIT FEE FLOOD LONE APN
consumer the project(Sec 7844,Business and Professions Cade:)The Contractor's
License law does not apply octan owner ofpropeny who builds orimprovts thereon,and PERMIT ISSUANCE
almencoursmrsuchprojects with aconounor(s)licensed pursuant to the Contractors ALTER�DRAIN&VENT-WA R
License Law. FEE SUMMARY
❑ 1 am exempt under Sm. ,B&P C for this rwson BACK ROW PROTECT.DEV LCE UTSIDE HIES
SANITARY Y
Owner Date DRAINS-FLOOR.ROOF,AREA.COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ em'Coyaffirm mandonllhaveam,aormofcomenurever' ec.39 ofacenlBc which FIXTURES-PFR TRAP RECEIPT#
Wmken'Compensation lnsumnceoracenifiedcopy thereof($ec.3g00,lab CJ which PARK FEE Y
rs all.mpinycv s under this permit.
GAS-EA.SYSTEM-I INC.4OR
Policy p UTLLTS T:CEIPT p
RUILDING DIVEST
Cr y GAS-EA.SYSTEM-OVER EA)
�nifed ca hereby famished. ( PLANCHECK FEF,
py is
CenlEal copy is filed wi 0t he city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF F,XF,MPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
COnsumion.eeddor becnmp1cmd lithe pewit is find.hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
Icodify that in the performance ofthe work for which this permit is issued,I.shall WATER I(EATER WNENT/ELECTR
m employ any person in any manner so as m became subject to the Workers' PAID
z Compensationlawsof California. Date WATER SYSTEM/IREATING Date Receipt Applicant
z0 NOTICE TO APPLICANI':If,after making this Cenifcaa of Exemption,yno should NEW RESIDENTIAL,PLM B. SQ.FT. TOTAL:I-" ^ breomt subject to the Worker's Compensation provisions of the Labor Cade.you must
forthwith comply with such provisions or this permit shall be directed revoked. BUILDING I9?E
g Q 00
CONSTRUCTION LENDING AGENCY ECONS�UMION
Z) z I hereby affirm that mea is a construction lending agency for the performance of 70
U Q the work for which this permit is issued(Sat.3097,Civ.C.) TOTAL: OO
Leaders Name
ULeader's Address QTY. MECHANICAL PERMIT FEE
I ccnify that 1 have mail mix application and nim drat me above information rs
contain.lagrce t.comply with all city andcaumyordinances and sate laws relating to PERMITISSUANCE [
building construction,and hereby suthorine.epresemativemfthis citymemer upomhe
U z ahove-mentioned Impiety for inspection purposes. ALTF.RORADOTOMECH. AX
(We)agree m.mve,indent y and keep bamdees rat City of Cupenino against
liabildies,judgments,costsamle hick yinanywayaccrueit drutsaid City AIR HANDLING UNIT(TO lo.000 CFM)
in cunscgaence tin anis permit.
( , m /1, 1 AIR HANDLING UNIT(OVER 10,000 ME) q
Sigmtuanf AppbcnngCommicmr — atm— EXHAUST HOOD(WIDUCTE PAID
HAZARDOUS MATERIALS DISCLOSURE? HEATING UNIT(TO TWITTED BTU) Date Receipt#
Will the applicant or future building occupant.store or handle hamohous material
as defined by me Captain.Municipal Code,Chapter 9.12,and the Healer and Sar.ty HEATING UNIT(OVER 103,000 RTU) TOTAL:
Cale,Section 25532fa)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
ROLLER-COME'OHP OR 1 W,OW BE ISSUANCE DATE
• Will the acortannmrfuare budding by the Bay Area it Quality Management P N, 8
hvardous air cnntaminanu u defined by the Bay Area Air Quality Management BOILER 100,0110 BTU)
)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PE AUG
I have read the formal s trials requirements under Chapter 6.95 or the yGI d �y
C:rlifamia llealrh&Safety Codc,S Iinn.s25505.25533 and 25534. Iunderxmnd thin �
if the building does not careml ,vest temnt
a .t t ismyiespnmibir ymn ifyme C(�"`( Ut VDI' U
m (cn must bo'md
occupant aft cto ixsua f a Ceti cam of
Ixenpanty e i 1 1 4� '^1I r��� sem.
,oranirum onmra ent ate TOTAL: ISSUED BY.�+`T- /—�s+7.�/-.CGs
OFFICE