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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1u...UINo..-ELEMICi ,
BUILDING DIVISION APPLICATION/PERMIT DINGPRNJECUIDIANIFIC
BUILDING PROJIi(TI'IDNN'I'IN'ICA'TIOry
PERMITNO,
278 �I9
L o (•}
BUILDING ADDRESS: P
p(V123 Via / a- Q UNITAXI LOT In �
SANITARY NO.
APPLICATIONSUBMITTALDATE
OWNIiR NAME: Pit N
CONTRACfOR'WME: LIC NO:
NICE:
❑
CONTROL#
—
Q i o O DDO
Vw rt e �^
iARCHITECT/ENGINIiIiR: LIC NO:
ADDRESS:
CONTACT : (/�F PHONE: (� /.`
/�C e C40O eP Gp P36e�eo
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELECT PLUMB MEC}i
BIR
PERMIT ISSUANCE
LICENSED CO CfOR'S DECLARATION
I heuhyallum that 1 amlicenudunderpmvisionsrfC pur9(commencing with�--5
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
fullSecorceandofetDivisionJof the Bmin<u and Professiom Code, and mylicenu is in
full force and attar.
PANELS
��
Limine Class
100
Co.
Dam ComrvcDr
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plana shall h u
ud ns public record,
SQ. FT. FLOOR AREA
/I
I• ti,aea !�m'e
E/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
O, I sift exempt bomb,
1 hereby affirm.(e thm I um exempt from the Gonion la License Law for Ne
SPECIAL CIRCUIT/MISC. )
TEMP. METER OR POLE INST.
Businessmprmal Co de: Any city
whichNicosia,
equire a permit to co31.5,
which requires permit m improve, demolish,
improve, demolish, repair any alructure
structure
o mm,the...he fi
throvisins
LM( aftersouChapter
POWER DEVICES
that he is licensedanlsarequlrh of theuch
Cotramous License
Licenu Lew (Chapter
thus he is nci ng w pumwnt to the provisions of the Contractor's Business
(commencing Division
9t officeeed
SWIMMING POOL ELECTRIC
VALUATION
he is Any vaysCWe)
that dentition and the the exemption,
Section 7irexempuherefmmnt l the basis for theasegedexempti to. pnyvidaBanof
Section ]thI S by any
doll lin n permit subjects the applicant to n civil penalty of
OUTLETS - SWITCHES -FI%TURES
hundred
not mare than Eve hundred dollars I$5010j.
❑ l,aode wrk,
ycmpinyeeswi@wegesesthe(Saar. comPwsiness
NEW RESIDENTIAL ELEC R S . FT.
Q
STORIES
TYPE CONSTRUCTION
will Bothe work, and the
and the smactum is
is not imenJW n ]Dant Business
and Professions Ctvle:'fhe Contractors
he Cour License Law dos
Lew docs t apply
apply tow owner of
nwho
property wyces, pdsorimpraveuch improve who caressuch workhimulfar throughhis
or
1 era, prnviJMthetsuchimr a
amp oy improvements intendMmpletiod forao,amet,
OCC. GROUP
RES. UNITS
hawevecillhathe vl the burden of einem is xoldwi id noneyeu or impmeifortheowner-
builder will have the burden of proving Rlet he did not build or improve for prrrpou of
T AI:
Qom' PLUMBING PERMIT FEE
❑ 1,azownmof the property, un exdusivdyconwaing ani,hlicwudconunetorsm
FLOOD ZONE
pPN
common she project (Sec. 7044, Business end Profusions CMJ The Commences
Licenu lawdmwam apply town ownerofpmperry whobuildsorlmprovessheldan,and
PERMIT ISSUANCE
whocommnsforsuch projects with scontnetoga) licevM pursuant ConmemJs
Licen=w.
ALTER )
FEE SUMMARY
❑ I sin exempt under Sea , B & P C for this mann
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY N
P.ECEIPT#
Owner Dau
1,
DRAINS- FLOOR, ROOF. AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Iherchy affirm rhmlbeve sceni0cme of conunno ulf-insum, orattrrifiweof
Workers luxurnmarma
ermit. fiM copy thereof(Sa.3800, LabCJwhich
RECEIPT#
MIXTURES -PER TRAP
PAR%FEE Y N
en all emplayre's under this permit.
this
Policy p
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4IRA)
PLANCHECKFEE pg�'
BION
❑ Certified erpyishereby fumishad.
ORWE41NDUSTRL WASTE INTERCEPTOR
GRADING TEE
❑ Cenifed copy is fled wiN the city inspection division
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM G. 200FT.
ENERGY FEE
(This section need not be completed ifthe Permit is for one hundmildollam(5100)
or less.)
WATER HEATER WIVINTIELECI'R
I certify that in the Performance ofthe work for which this Permit is issued, l shall
not employ any peraon in say ..net eo not to became subject to the Workers'
PAID
Compemsaion L.waof Califomio, Date
Applicant
WATER SYSTEMITREATING
Date Receipt#
NOTICE 9'0 APPLICANT: If, afar making this Confirms of Exemption, you should
became subject n the Workers Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PIN B. SQ. ET.
TOTAL:
forthwith comply with such provisions or this permirshAl be domed revoked.
BUILDING HE
r
CONSTRUCTION LENDING AGENCY
SEISMIC FEE 21.70
1 hereby affirm that hem is a co moretion lending agency for the performance of
the work for which this perrnat is issued (Sec. 309], Civ. CJ
Lender's Name
TOTAL:
ELECTRIC NEE D
J N
Lender's Addms
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify ,hos I have and this city
and application and sou that the above information mtudon is
building Iagm to comply county ardinwceswdsuu lewaulatin
witfty
PERMIT ISSUANCE
MECHANICAL FEE
� N O
and anryand
the
stansengcntumed mpert herebyemhariureersea ova of lhisciry menterupon the
.MvemcnsionM property for inspection p.ryoua.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX /+
�VJ i
(W ) agree t save, indemnify and k«p hmmlesa the City of Cupertino agaims
liobiliries,jud anrawdex coon whish may in any wayocaue agvmtsei Ciry
AIR HANDLING UNIT (TO 10.000C [i)
in consegse, UIZIrans�in ;sp_erm.�-. / /�
G ���
AIR HANDLING UNIT (OVER 10,000 CFM)
¢ —
S�iurdoTAPP�amUCon,rec,or IST/ Date
EXHAUSTHOOD(W(DUCI)
PAID
HEATING UNIT (TO 100,003 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dau Receipt#
Will the applicant or future building recupam store or handle hauMous materizl
as defined by the Cupertino Municipal Code, Chapter 9.I2, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
aa�
VENTILATION FAN (SINGLE RFSIDI
Cede, Section 25533(s)7
❑ Yea 1:1 Na
Will thea applicant or future building ecu tuuc tmdevices whichemi,
PP a pan qui
BOILER- COME (311P OR Fiat BTII)
ISSUANCE DATE
BOILER - COMP (OVER 100"00 BTU)
formations air contaminants nes defined by the Bey Arta Air Quality Management
Air
District!
pT p 0 raw
V' �y
❑ Yes ❑ No
W
NEW RESIDENTIAL MECH.—SQ, FT.
California haveof the
1 have uud @< hmnMo e. Sectionsa requirements under Chepur understand
Ie alth fazed@ Safety Cede, Soman.l%05, Oren and 25534, Ch Iter 6.9 o that
(I 19
OCT�/ Ni
if the building es not currently he,..ten.m,thm it ie my responsibility mortify the
mcupunt n c requiremenI It b must he met prior to issuance of enaf ate of
�s T'
Oce O
V�I i i�� III;Ijl kL I f'lik
ISSUED BYE+ W • a
(We, or authorized agent I Date
TOTAL:
OFFICE