28020APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUMB N .. ELECTRICAL
APPLICATION/PERMIT PINGPRNJECTIDEN'TIFIC
BUILDING DIVISION BUILDING I'ROJE:C'1'IDEN'1'IRICn'1'ION "
//�
I'I:ftMI'I'NO. /1 O O L O
Lo
BII ,DIN/nGJ ADDRESS:
SANITARY NO.
APPLICATION S(UBBMIITTrAAl. DATE
// v9
�/x'O UNII'p LOT � /
"`+++
O ERS NAME: PI{gNE:
eafntd N
C NTRACfOR'S NAMG: LIC NO:
GtJT U L
NIC
❑
CONTROLN
HITECg1ENGINE : LIC NO:
"Lc5Ca'"u
ADD ES:
PLT/ L iA22{' o
CONTACT: PHONE:
Q-1-Y. (ELECTRIC PERMIT FP:E
BUILDING PERMIT INFO
IlLDO 3LECT PLUMB MliCll
PERMIT ISSUANCE
0 ❑
LICENSED CONTRACTOR'S DECLARATION
ache 1 )
GC2 yn pmvisi.ns. pmr(commercing with
I hereby ffDivisi Division
� 00 .n l of rhe Business and Profusion Cede. and my licrnse is in
Section 7000) and
full fmccaaJ.ffwl.
effect.
APPLIANCES - RESIDENTIAL
�D IPf10
PANELS
<zw
IQ„ZW Li cense Class Cont
m=y Dme
UP T02f0 AMPS
rECTS Dainer,r
Z �O,z ARCIIITCCI"S DECLARATION
O Z—M 1 understmd my plans shall he used i s public swords.
Q;jf
OVER I1#AMPS
OVER IIIOOAMPS
SQ, FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
%'W OWNER-BUILDCR DECLARATION
XO: ". I hereby affirm that I am exempt firman the Contractor's License Law for the
w3a.y following mison.Xecdon 7031.5, Business and Professions Code: Any city or county
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE. INST.
which requiress#emit tormsomcLaltos,improve, demolish, m tepid, any.1anwre
K WQ� prion. its issuance,elso rcqulms the applicant fsrsuchpermiOo file. signed see¢mem
ea: < that he is licensed pursuenrto the provisions ofthe Contractor's license Law (Chapter
d0.o� 9(c.mmencing with Semina]Il(I(pnf0ivisionlofthe Business and Profession Code)
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
Xty_rn or lhm he is exempt hercl'rom and the basis for the alleged exemption. Any violation of
ZZ,,> Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OUTLETS- SWITCIIFS -FIXTURES
Q� t murethan five hundred dollars ($500).
C o n❑ Lnowneroflhepmpcny.nrmyemployttswith wegessstheirsolecompenzution.
. ]Ik4,Business
will do the work, and the structure isnot intended oroffcred fnrsaI
NI?W UFN LELCCTR _SQ.IT.
STORIIES
'TYPE CONSTRUC'T'ION
and Professions Code The Contractor's License Law does noto an owner of
properly who buildsorimprovesthemon, and whod.essuch worlforth,.ugh hiOCC.
rwe emdloyecs.providedl lhmsuch improvements atom mendemcd to .Ir,however,
GROUP
RES. UNITS
the buildingor improvement is sold within one yen of,t towner-TOTAL:
builJer will hove the buNrn of proving that he did not build e lin purpmu ul'sale.).menclnsivelyconv
QTY.PLUMBINrPERMIT I°EEFLOODZONE
cting withd contmctorsto
AYN
construct the project (Sec. 7044, Business and fessions Che Convector'sLiceseLawdocsnol... yman.wmernfpr.Krt hnbuildsmveatheass,and
PERMIT ISSUANCEwhoamlrecb
frsuch pmjttts with a contractor( licensed purstbe C.ntmcrors
Law.
( )
Af TER-DRAIN B:V -WATER IMLicense
FETE SUMMARY
❑ I em exempt under Sw. . R for This reason
BACK PLOW PROTECT. EV ICF.
OUTSIDE FEF:.
SANITARY Y N
RECEIPT' #
Owner Dale
DRAINS -FLOOR, ROOF, R[A, :OND.
WORKMAN COMPENSATI NUE: ARATION
SCHOOL TAX YN
❑ Ihcreby affnnthallhuvcucenifcme of ...main elf-inure,ora edit '1.
Wmkere'Compertsation lluuranre orettrtifmr copy the ft5 .3 CJ
PIXTIJES 'HR TRAP
RECEIPT al
PARK FEE Y N
rovers all employce'.a under this permi6
Policy #
RECEIPT#
M CAS;, .SYS IN .4 OUTLETS
BUILDING DIVISION FEIis
Company
GAS -FA. M-OVER 4(EA)
PLABZHECK FEE
❑ CenlfMc.pyish... by fumished.
GR DUSTRL WASTE INfERCEPf00.
GRADING fI'iE
❑ Cenifed copy is filed with the city ins Ilion divisio
CERTIFICATE OF EXEMPT ON FROM WORKERS'
, EASHTRAP
SOILS FEE
COMPENSATION NSURANCH
SEWER- SANITARY - S'T'ORM EA. 200F1'.
ENERGY FEE
(Thisseviamoeednatbecomple,difrh pcomilisformuchundrWdiAlars($100)
or less.)
WATER HEATER WryIENT/CLCCTR
Icertify that inthe perfommnce of the we forwbich this penldl is issuul, l all
not employ any person in any manner so us o become subject to rhe .Kers
PAID
WATER SYSTEM/1'REATING
Oz
Z 0
Compensation Lawsof Cnlifomia. Data
Applicant
Dme Receipt#
NO] ICE TO APPLICANT: ILattermaddrg this Ceaifea`c of ?xcmplion,ymt should
NEW RESIDENTIAL PLMB. SQ. Ff.
TOTAL:
(q
become subject .,he Workers Compensation provisions ofthe Tabor CMe, you most
lirnhwhh comply will, such provision it, this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
ELECTRIC FEC
W z
5
V O
CONSTRUC'FION LENDING AGENCY
1 hereby affmt than the. is a cnnlrvnion lending.grncy far Be, performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
Lender's Name
Lender's Address
QTY. MECHANICAL PERMIT- IEE
PLUMBING FEE
U
I2a
V 7
I cenily that I have read this application and sate that the above information is
corem. I agree to comply with all city and county om innnces and state Taws retailing to
building counantion, and herchymo nricomprceroadives nHhiscily toenterupan the
above-mcntionM propcny for inspection purposes.
PERMIT ISSUANCE
MECHANICAL PEE
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
G
(We) agree to save, indemnify and keep harmless the City of Cupertino against
eagsleth City
liabilities judgments,cnsex andexpenseswIf h yinsnyway cmsln
AIR HANDLING UNIT (TO 10,001 CPM)
inconscquentto ming of this permit.
AIR HANDLING UNIT (OVER FLOW CFM)
sr
EXHAUST HOOD(W/DUCD
PAID
igalto pplicunt/Co tactor mo
HEATING UNIT (TO 1(8.X10 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building residual to. or handle hamrdous mammal
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
IIEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RFSID)
Code, Section M532()?
11 Yes El No
BOIL(?ft- COMP (31iP OR 100,000 B1U)
p S A�yVE DATE
1f� � y
WilDheapPlicanmr(uambuilding«cupant useequipmcmardeviceswhichcmit
BOILER- COMP(OVER 100.000 BTU)
dous air comaminaoa n defined by the Buy Arca Air Quality Management
uzn❑ Yes ❑ No
Otsmct7
MAY 111995
'NEW RESIUI?NTIAI,MCCH. SQ. FT.
1 have mad the hnardesus mmerims lexperemems under Conduct 6.95 of the
Califamia Health & Safety Code, Sections 25505,25533 and 34. T understand that
sI �� Lt�
91"'y
V Vf LUI-EH INU
if the building docs not currently have a lrnam, that it is my responsibility to notify the
.ccupant of the requvements which must he met prim 1. issuance of a Certilicale of
Occupancy.
ISSUED BY:
Owner or authonuld agent Date
TOTAL: