28163 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO
BUIL)IG-ELECT RICAI, PERMIT NO.
APPLICATION/PERMIT PI.IG PRO C CT IIIEANIFICA 28163 8 al 6 3
BUILDING DIVISION BUILDING PROJECT IIIF.N'fIN'ICA'I'ION L il.\FJ�Vl
BUILDING ADDRESS: C}1p/ yn SANITARY NO. APPLICATION SUBMITTAL DATE:
(2 U Jit-{/1✓l &(A�NIT# LOT# 644
OWNERSNAMH: PHONE: COMBACI'OR' NAME: ( LIC NO GGGJJJ _N7
K M c�kh UyyZy
NIC CONTROL#
ARCHITECf/ENGINEER: LIC NO: ADDRESS: �+
5 , -41 ❑
CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMITINFO
BLD EI.EqF
PLUM MIiCH
LICENSED CONTRACTOR:SDECLARATION PERMIT ISSUANCE MECH
APPLIANCES-RESIDENTIAL )OB TSC
pyy Ihe")ofirmlhm E 3 ofthnsedinss and isionaofCTm¢r9(rommecense with ��
00 SatforceadefDivision Jof the Business and Professions Code.and my license is in ppryBLS
W full force and effect. e'er
License Clau�Liap Se�yyZ9 UP TO 2W AMPS
y6y Ume Cast 201-IBM AMPS
70`r'Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FI'.FLOOR AREA VSQ.FL
OZ'`30 IundersenA my plans shall be used a.%public records.
FN , SIGNS ELECTRICAL
Liersed Professional
E Y=< OWNER-BUILDER DECLARATION SPECIAL CIRCUI'I'/MISC.
KOiU 1 hereby affirm nhill 1 am exempt from the Connector's License law for the
{D3O-r~Qn fallowing onson.(Strohm 7031.5,Business and Professions Code:Any city or county TEMP.MET ER OR POLE DIST.
�mJ which quires a penni,to commit alter.improve,demolish,or repair tiny structure
ETI into to it,iavuun.'.1koarylms,hoappliumt lot suchpennL 1.Eleasi,ed...tanner, POWER DEVICES
W p0that he is liuemed pmsuunt to me provisions of the Contractors License Law
Fc
d eLL 9(commencing with Section 7009)of Division 3 ofthe Business and Prolcssions Code) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exempt hertfrnm and the basis for the alleged exemption.Any violation of OUTLETS / �.�
FZa Section 7031.5 by any applicant for a permit subjects the applicmuoucivil penalry of FIXTURES K
G no,mom them five hundred dollars(SSW).
W m ❑ hasownemOM1epmperty,nrmyemployecswithwages asmeirsnlecrmpema,ion, NEW RESIDENT[AL ELECfR _SQ.FL SIORIP 'fYPIi CONSTRUCTION
a will do the work,and the structure is not intendedorrffered heretic(Sec.7W,Business
unit Professions Code:'I'he Contractors License law does not apply In an owner of
property who huilds or ltnpmves thereon,and whodocssuch work himself...through his
own employees,provided thatsuch improvementsumn(itinwndedorrffered hassle.If, OCC.GROUP RIS.UNITS
however,the buildingor improvement is sold within one year of completion,the owner- TO'
builder will have the burden of proving that he did not build or impasse for purpou of
salt.).
❑ 1. vowneronheprnpeny,amexclusivelycontectmgwithlicensedcontmctonto QTY. PLUMBING PERMIT FEE FLOOD ZONE ARN
construct the project(Sec.7044,Business and Professions Cod"IThe Connector's
License Lammas nmnpply to an ownerafpropeny who buildsmimprovevhoern,and PERMIT ISSUANCE so
whocomraesfaraucn prajee..Wim aernwmarts)Immse<lparaenm mmecanteCOOra nI.TER-DRAIry&vrNT-WATER PLL SUMMARY
License Law. (HA) FEE
❑ I am exempt under Sec. ,H&P C far,his reason BACK FLOW PRO'I'ECT,DEVICE OUTSIDE FEE.
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIP #
c WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihcreby affin(rthat l have a certificate ofcoment to self-insure,or a cenificator( IXTURFS-PER TRAP RECEIPT#
Workers'Compensation lmumnceor a certified ropy therem(See.JAW,Lb C.)which PARK FEE Y N_
f Pavy all empinyea:ad^�i� �_L S�/G.3�7`)�03ECEIPT#
GAS INC.INC.40UTLETS BUILUI NO DIVISI Fit liS
Cnm'soll YT 's•+f q_'satr"j4'a Jwt GAS-EA.SYST -OVER 4(FA) PLANCHECK PER
�Cerdfied copy is hereby furnished.
(11191 t
❑ Cenified copy is fled with Ne city inspection division. GRFAS USTRL WASTE INTERCEPTO GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SETRAP SOILS FEE
COMPENSATION INSURANCE
Thissec,ion need nmlmcnmpletediftbe permitisforonehundred Jolles(SIW) SEWER-% 'A ORM EA.2WFhENERGY FEE
n less.) AZ
I certify that in Ilan performnnceof the work for which this permit is issued,Ishall WATERW/VHNT/ELECfR
non employ any pceun in eny manner so as as become subject to the Workers' pili
Compensationlawa Of Culifmnia. Dae STEM?RI? 'll «fp,#
Applicant
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should RES IAS B. SQ,PI'. TOTAL:
FQO become subjectto the Worker's Compercooma previsions rime Lnloos Code.you mush
forthwith comply wi ah such provisions or this permit shall be deemed revoked. BUILDING E If
CONS"FRUCTION LENDING AGENCY SIi15MIC ETF.FE
Z IhembyafOma film there is a emmalaction lendingagcrcy far th,setio,mance of fAl MCONIMUMONTAA
FEE
U O the work for which this permit is issued(Sec,3097,Civ.C.)
Lenders Name
O U I<nJers Address QTY. MEC NICAI.PERMIT FEE
1 certify thna 1 have rtnJ this application and stem that the ehnve inmm,etion is
correct. I agree to comply with all city and county ordinances and state laws relating to PERMI ANCE
F" building construction,and hereby authorize representatives ofmis city meaner upon the
U 7 ubovcravrooned property for impeaimi purprsox. ALTER OR ADDI0 MECI I.
G' (We)agree to Sava,Indemnify and keep harmless the City of Cupertino against
lhdalitiea,judgmcnts,cosI dcxpenses which may in my way accrueaguinst said City AIR I IANDLING ON IT(T0 l 0,1X10 CFM)
in conseque fthe
AIR HANDLING UNIT(OVER 10,000 CPM)
Sign of Applicant/Comecmr aYt/ Date EXHAUST HOOD(W/DUCq
PAID
I IAZARDOUSMATERIALSDISCLOSURF. HEATING UNIT(TO 1110.000 BTU) Dam Receipt#
Will the applianm or Allure building eeetioad amre or handle It...odous material
as defined by the Cuperninu Municipal Coca,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100."111 U) TD'IAL:
Cale,Section 25532(a)'t
❑Yes El No VENTILATION FAN(SINGLE RESID)
BOILER-COMP.(3HP OR IM.003 BTU) ISSU C DATE
Will me acontan torfctue building by the ay equipment unlit c Managementhemitt 1P
hazardous air contaminants as defined by,he Nay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Y' l)
UiatricC
❑Yes ❑No NEW RESIDENTIAL.MECIf. SQ.Ff. I
I have read the Ire>ebaus materials mgriremert.under Chapter 6.95 of,he JUN
0
8 19a,
California Health&Safety Code.Sections 25505,25533 and 25534. I undcrsend that Ci/ v J
Hills building does not currently have a tenant tem it is my responsibility to notify the (Jp
cupant of the requirements which must be mel prior no issuance of a Cenificme of list ✓r
Occupancy. J
Owner m authorized agentDale TOTAL: ISSUED BY:
OFFICE