28314 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING.MECHANICAL 28314
BUILDING DIVISION IIUII.OING 1101—IF IDENTIF'ICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLTCA'IION SUBMITTAL DATE
`7 L2(43 UNIT# LOT# 9/45;a�-_
OWNERS N/std l+,;mr � � I'I IONI?i� � CONTRACTORS AME
� S 00�i 1)0/ N/C CONTROL#
ARCIIITIiCI!'/I".NGINIi1:R: .IC NO; ADDRESS:
Ono ._��^ �. W` `j^1 95720
CONTACT: PHONE: xa//((..—ll F-I J VT 7J'
QTY. L'LIiCTRIC PERMIT FEE 6UILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE OO ® �vh E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEM'IAL
Sa'
OzZ Iherebyaff,.red lemliccnsed underprovisionaof Chepter9(commencing with JOB DESCRIPTION
�WOC Section 70011 or Division 3 of the Business end professions Cade,and my license is in PANELS r
to full forte wd effect F-a
�zw I.icens "a6a. _ZO Lic.p Ll"73F701 UPT0200AMPS / aN/
vs60Do e 1(�— Comm �S 201-10110 AMPS V
Z�yZ ARCHITECTS DECLARATION Q.FT.FLOOR AREA SrSQ.FT.
OVER 10(10 AMT'S
OZ-0 1 understand my plans shill be used m public records.
P„2tma - SIGNS EI.ECMICAL
Q �7Q Licensed promotional OWNER-BUILDER DCCLARATIONSPECIAL CIRCIA Div1SC. L
COaU 1 hereby appall that 1 am exempt from the Comment' License Law for the t
luau-rFQi� fallowing teasers(Section 7031.5.Brain., it Enchanter,
Code:Any city or county TEMP.METRR OR POLI:INST.
�1OJ
which m4airca u pemtino construct,alter,improve,dental ish.or repair any structure
yY� m it,isxuance,.Isone rites the applicant for such Ito file a signedstatement POWER DEVICES
pear 9 ps penal
thafhear,ois ensedpesunnnn0010).the iviki of rhoC fitoine..nal nsel.vi.na Cater
d o�' 9fcan heis.ngwithuervirn]WO)of Division Sof the Businessand Professions Code) SWIMMING POOL I?LECI'RIC VALUATION
pt_y orrhm M17031.5 by nyappomand the reportss f subjects
thedexemant to civiny l
of OIITLP.TS-SWITCHES-FIXTURES 0 J
tS•ZQ Section than
hadledd afor a pplicant subjects 0e upplicenuoacivilpenahy of
d comms than five hundred dollars($500). NEW RPSIUENTIN.1?LECIR SQ.FT. STORIES TYPE CONSTRUCTION
av n❑ I.mnwnerofthepropeny,mmyemploymswithwugesmtheinolecomMnsution,
y will do the work.and thesweure is not intended oroffbred for sale(See.]Bf4,Business
and limitations Code:The Communes License LW does not apply to an owner of
panpenywhnkildsmimprovesdtereon,and whodoea such wnh hiesseiforthroughhis
ownemployeax,proviJed that such impmvememsarc not imm�dedoroffcmlforsale.IL OCC.GROUP RFS.UNITS
however,the buildingmimprovement is sold within one yeurofcompletion,iheawner- 06
builder will have the burden of that he did not build or improve for purpose of TOTAL:3
proving pmv p rya
sale.).
❑ I,mowner office propeny,am exclusively contmming with licensedconcommrs to QTY' PLUMBING PERMIT FTE FLOOD ZONE ANN
construct the project(Sec.0044,Business end Professionals Code:)The Contractors
License Low does not apply to an ownerofpropeny who builds orimproves thereon,end PERMLJ ISSUANCE.
Lraasfnrsuch projects withacontracmr(s)IimnuA punuunnnthe Gmtracforx ALTER-DRAIN&VENT-WATER(EA)
License ceuc haw. PEE SUMMARY
❑ I um exon under Sec. B&P C for this re.son BACK FLOW I'RO'rEC'1'.DEVICE oil
SIDE Lh5
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby strum that l have neenifiwteofcomenuomlf-insure,oraccnificafeof FIXTURES-PER TRAP RECEIPTN
Wmkerv'Comprmation Insurance or a conned copy thereof(Sec,3800,Tab C.)which PARK FEE Y N
covers all crop epllisper)at.I GAS-CA.SYSTEM-1 INC.4 OUTLETS BUILDINGRECEI IIs FEIiS
Pa crop
/IO ZZ.\d-'1
Company IO LC f GAS-CA,SYSTI:MAVER 4 IEA) PLANCIIECK RLE
❑ Cenified copy is hereby famished.
❑ Codified copy is fled with the city inspection division. GREASEjINDUSI'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION(MOM WORKERS' GRL'ASETRAP SOILS FEE
COMPENSATION INSURANCE
Ghinaectionneed narkcompletedifthe#trait is formchmobacdollvrs(SIW) SEWER-SANITARY-S'T'ORM EA.200FT. ENERGY FEE
or Ins.)
Icndly,hat in the perfonnnneeofthe work for which this#scoot is issued,I shall WATER I IFA'I'ER WNENTp:I.ECTR
not employ any person in any manner so as to become subject I. the Workers' PAID
Compcnsmion Lvws of Cnlifomia. Dam WATER SYSTEMR RHA9'ING Data Rceripl#
O OApplitum
NOTICE I'O APPLICANT:If,ofnr raking this Certificate of Esempfion,yaushauld NEW RESIDENTIAL PLM. SQ.FT. TOTAL:
r V1 kasmesubjarto the Workers Compensation proviamm.fthe Labor Code,you most
Chi 7 forthwith comply with such provisions or this permit shall Ne deemed revoked. BUILDING FEF.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE CJ - i•
O z I hereby ardent that ahem is a commuction lending agency for performance of .J
U O the work for which this permit is issued(Sec.30)7,Civ.C.) TOTAL: ELECTRIC FEE 3O% cc)
Isndet's Name
OU Lenders Address QTY. MECHANICAL PERMIT FTE PLUMBING FEE
U I cenify that 1 have read this application and terminal the above information is MECHANICAL FEG
a conoct. legrcemwmply with all city.nJ county ordinencm and xmm laws relating to PL'RMITISSUANCH OO y l7�
I-' building construction,and hereby emhorise representatives ofthis any nerncr upon he CONSTRUCTIONTAX
U Z above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
(We).gree ,,save,indemnify end keep harmless the City of Cupertino against
habllifics,judgments,costs and expenses which may in any way accrue against sold City AIR I IANDLINO ONO(TO Might CFM)
cnn,cyuenco of the grunting fthis pemdt.
AIR HANDLING UNIT(OVI?R 10.000CFM)
Signature of Applanot/Cconomme Dam EXHAUST II U( OCT)
PAID 4—�`O�f� O
HAZARDOUS MATERIALS DISCLOSURE IEA'TING 'T('I'O IX%"BTU) Dare Receipt#
Will the applicant or future building occapa t Bore or hnndk hazardous"anti
mdefinedbythe Cupertino Municipal CWd,Chapnr9.12,andfhe Health fc
❑Yes ❑No HEATING I (OVFiR IIMI,DOB BTU) _- TOTAL:
Code,Section 255322553200? ' '//
LA#'ION PAN(SINGLE RF_SID) �X {�pNt(�q��
Will theapplicnnt or future buildingocmpant usceruipmenl ordevi a chemic ROILER COME(311P OR 100,000 BTU) AUG
( �[I[7C
hazardous air comeminants m defined by the Boy Area Air Qu iD' ageme R ILER-COME(OVER im,"BTU) fAW IIMe JJJ...V "�J
DI61rimP
❑Yes ❑No NEW RESIDEN'TIALMECII. SQ.FT.
CIl`t Vr vur ci I IN
1 b.ve read the notation,mmermis rNorman,
orma s r .hapnr 6.95 of the
itthernl nllanith&Safety Calle,Seeioannum,25505,251it is y 255-4. l undcrsai f that
Ill.teama ,fil Jtresnmeurrendykve.atnem,at that my oorstyns nmify the
L cupnm of Ire rtquiremnns which..at k at prior to iasuvncu of a Certificate of
(kcupuncy.
Owneror atuhnrimd a mm Data TOTAL: S/3 G0 ISSU17D BY✓ CI
OFFICE