28431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R ILDING-ELECT RICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT rLUMBING-MY.CUANICAL 28431
HUILIIING PROJEC'1'IU' 'PION
BUILDING ADDRESS: SANUARYNO. APPLICATION SUBMITTAL DAM
1�0 00" Zo3oo SM ENS (f4?45EX SLO
UNIT. p
NERS NAME: VII N/C CONTROLp E: CON NAME: LIC NO:
r
s vM��c 995-3`���
ARCICLICO: ADDt;55: 11
cON'1'ACT: PHONE: 4 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/ � IPERMIT ISSUANCE DC PLU MF.CH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L�1)Y` 10B DESCRIPTION
OKZ Ihereby of ondett l am licensed underprovisionsofChapter9(commencingwith
+t 100 Seclii,r7")af Division 3 of Tho Batman,and Pcpviunn Cod,andmy li.nueis in PANELS
ce full finceme!effect. -
0<,ZW License Class Lie,# UPT02MAMN
rn<y Date Contm for 201-IOOOAMPS
Z FONZ ARCfIITF.CTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.PI''
O2.—t] 1 undermined my plans shall he uuJ us public«coMs.
o m F'W SIGNS IiLEC1'RICAL 11.10
<Y�:j Licensed Professional
�5,t OWNER-BUILDER DECLARATION SPECIAL CIRCIAT/MISC.
Owu
p,F 1 hereby amffirthat 1 am exempt Gom the Comment's License Law forthe
3o. following reason.(Section 9031.5,Business and Professiore Cotte:Any city or county TEM 11.METER OR POI.E INS')'.
which requires a permit m comma,slate,improve,demolish,or If any swemre
priortoitsissuance,alsorequimstheapplicantforsuchPermittofileasignedstatement POWER DEVICES
ty 00 that he is licenced pursuant to the provisions ofthe Contractor's License Law(Chapter
as z 9(commencin with Section"/0011 fOivision3 a Business and Professions Code S MING POOL ELECTRIC
o tz, (commencing )o ) VALUATION
-, or shot he is exmrpulmrcfrom anti the hasis fn call geA exemption.Any violation a' -
�yQ Section 9031.5 by any upplicem fnrnpem' suhlciis he applicannnucivil pennhy .ETS-SWITCI(IiS-PIX'IURES'
t mom than five to nd¢d dollen(55 I� �
ca: 0 I,hsawmrofth, rn NEW RISIDENTIALF.LECIB _SQ.FT. STORIES TYPE CONSTRUCTION
❑ p perry,nrmy ployees with agesestheirsnlecompensatinn,
a will dmhe work,and the smucum i mintendedero(f ed forsale(Sec.]01Q Business
and Professions Code:The C tactors License Low oes not apply m an owner of
property whohuildsurimpr es therean,nnJ whndmss ch workhimsclfonhmugh hie
nemplu.........
ces,prnviJ 1 msuch improvenarroauerm'mendeJmoffercdonsale.If. OCC.GROUP RES.UNDS
M1 wevegtreb ' orimprovementia mdd w' none arofcomplctionJhe owner-
builderwillh6 etheburden o(prnving lFm Jit pot bu ld orimprove for purpose of
sv1eJ. 116 QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
a Les owns of the ny, �/hy Ivelycommnmg licenudcomm�orsm
nstruct the p 'ec dsiness end Profs as Cade)The Contractors pF.RMI'1'IgSUANCB
License Lawdaes �U wnerofp perryy'at it Js or pro thelnon,and
whocomewnifnr..chip (( withaeonmao sjlirm In, aunt to the Contractor. gLTF.R-DRAIN&VP.NT-WATER(HA)
License taw. ((\kl/ FEE SUMMARY
❑ I um exempt a Acr Seg/ ,N&I'C for IM1is reason )JACK FLOW PROTECT.DEVICE ° 'I:LS
SANI'T'ARY Y N
Owner pate T:CEB T N
WORK N COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA.GOND. SCHOOLTAX
❑ Ihffithat l have
erebyarm a cenificare ofconsem m wiffinsum,or a certificate CELlf
Workcn'Cnmpenseoion Insurance or acenifed copy thereof( lab CJ FlXTURES-PER TRAP which PARK FEEY N
revertant employee's Ilndonbts permit. GAS-IiA.SYSTEM-I INC.4 OUTLETS :CEIPT q
PolicyN UL GDIVISION FEES
Company GAS-EA.SYSTEM OVER 4(CA) PLANCUE K E Ts
❑ CrA fief ropy is hereby furnished. V
❑ Ccnifiedcopyisfiledwiththecity impectin ituov. GRP.ASILINDUSTRLWASTEBUMRCEPTOR G G +F, I
CERTIFICATE OFEXEM NFROM WORKERS' GREASCTRAP 5011.5
COMPENS ON INSURANCE
Clhis section need nor be m emdif the per mit is Intone hundred dellam(S ) SEVER-SANITARY-STORM IA.200FT. ENERGY FEE
or Iuxs.7 a
I certify that in di, pe anceo(the work for whit ispemrit ieieJ,lehl WATER HEA9'fili WNGNT/E1.IiCIR
nor employ any petwn i any manner so as t m jam t ark PAID
SM
Compensutien Law,of Ca foods, Date WATER SVS"TEM/TRGTING DNLN rate Receiptp
Applic t
z�z�-I C) NOTICE TO APPLICANT: Laftermaking i Beate x ption,yo should NEWRESIDENTIALI'LMIL SQ.PT. TOTAL:
t-I (4moi becomesuhjectmIn,Wrare'sc. comb vis' so t Labor Cade oommt Pill
tFF---�II fonhwith comply with suehp whi. sa panmit�h edeemW rev ed. BUILDINGFEE
W z CONSTR 1CTI0 , NDING AGGENCY SEISMIC ItiE
^a I herebyaffirmthvnhere ie v cantor on lending agency forth pedurmanceof
V O thew ork6m whichthispennitis sued(Sec.3D99,Civ.C.) ELECTRIC FF. —�
w �.I Leader's Name
0 U Lender's Address QTY. MECHANICALPERMIT FEE PLUMBING rE
U L cetfify ohm I have mad this a Hessian and amte tMt t above roar mmor is
Ui come.Iagrcmocomplywithallch ndematyoninancc. dxtntelawsrdmingto PERMIT ISSUANCE MECt F.
building consvudion,and hereby autho'zereprcsentatives ft bis city to eater upon the CON TI T X
V Z above-mentionedismprayfmiriNxerion urpous. TI-RORADDTOMECH, l
(We)iti to save,indemnify and p ha s the City of Cupertino against
linhilities,judgments,costs and expenses whit y in any way acerne against said City AIR HANDLING UNIT('I'O Fhuf CFM)
m con nee of the grunting fthis emlit. /% AIR HANDLING UNIT(OVER 10.000CFM)
Sig ureof ApplicanUConv to Date EXHAUST ROOD(W/DUCT) PAID
I IAZARDOUS MA I'ERIALS DISCLOSURE I(EATING UNIT(TO 100,000 BCU) Date Receiptp
Willtheapplicam on future building accupnot more.,handle Notorious material kIGTING UNIT(OVER IOO,IXq BTU) 'TOTAL:
a,defined by the Cupertino Municipal Code.Chapter 9.12,and the health and Safety
Cmr,Section 255326619
❑Yes 11EN
Na VTILATION PAN(SINGLE RESID)
W ill0o upplicmn nr future hnilding rc,rpnm nse equipmemm�levices wh ich emit
BOILER-COMPOHPOR 100,000BTLU ISSUANCE TE
hersrdous air conmmamun,to,defined by the Boy Arca Air Quality Management BOILER-COMP(OVER❑ 100,001)BTU) P ,4
District? B
Yes ' T
❑Nn NEW RESIDIAL MECII. SQ.1"1'.
I have rend the humodous materials"itimmems under Chapter 6.95 of the �• JUL 27
California l lealth&Safety Code,Sections 25505,25533 and 25534. 1 undcrarnd that , V
ifthebuilding
tedoes
n,'uhteunen w have aunion.
met His my responsibility to notify the C/ry a] $�
cupant.(she rcyuircmenrs which must he met prior to i.suance orf.v Cenifcate n( la 0�
Occupancy. 1.
Owner nr amhorized agate
Data 'f ISSUED BY
OFFICE