28245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n e I� ^ C
BUILDING PRO.IK(A IIIENTIFIC,A'THIN G o G 4 J
B
GILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNTN LOT# 11`
6
SWNL F: f M'RACI'OR'S NAME: - LIO: 111'aI CN
GL.ECC� votil5/G/JS "/C CONTROL
ARCHI'ECT/ENGINEER: LIC NO: J Sc ❑
CONTACT: PHONE: QTY,` ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BIEI Ccr PLUMB MECH
PIiRMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
y�Z I herebyaffinn that tum liCmardunaerprovisiovofCTmpmr9(cearmancing with 108 DESCRIPTION
Lt R
Own Senior 731 of Division Sof the Business and Professions Code,w my licenee is in PANELS F
y full face and eff (�J ��
F UU'Zty License Class Lm.M �� • UP DO 200 AMPS
m7y Date Contactor 201.IBM AMPS
OF�ZL, ARCH CTS DItCLARXI Ci OVER INS)AMPS SQ.ItT.FLOOR AREA $/SQ,17.
jZ� 1 ders and my plans sh aspublic recon .
y�W SIGNS ELECTRICAL
Lice iiCKry
�rBQ OWNER.BUILDER DECLARATION SPECIAL CIRCUVOMISC.
LCe. m oh
I hereby affam 1 an exempt from the Contractors License Law for the
u34w following resson.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
:1�ON; which requires a permit 1.mnstru t.tiller.improve,demolish,or repair ony srucmre
GWQ� to its issuance,also Claire,the applicant for such omit to File asi ed statement POWER DEVICES
prior PP P en
QeE
,,a 9mrn lie iwneirtscdpursction0phRof Divisinfthe Committees License Protecwns Cod(chapter
L dp�- 9(ntmmencing with Section]fX10)ef Division the Business end Professions Cale) SWIMMING POOL ELECTRIC VALUATION
yKj_,� or ohm he is exempnhcrcfram and the basis for 0e alleged exemption.
Any' I of UTLE S-SWITCHES-FIXTURES 1 1 y
FZa Sation ID3n5by egrromed cant6repcmtit subjects the eppliwnnoecivil penalty of l `� '`/`/
t mo¢then foe hundred dollars f5500). NEW RESIDENTIAL ELEC R _SQ.FT.
z � n❑ oche w work,
an thestrany,ermyempeadas offered forahe(Sce.cumpBosun , STORIES TYPE CONSTRUCTION
a
will Professions
sions end these C.Coo masot License Law doea., p,ly in a Business
tial Professions Cmc:The Commnor's License Law dos not apply to an owner of
ownpmpedywhob,provi ed thateathimpanctdwnoaeenot mandrdorofnedthnmghhf, OCC.GROUT' RIS.UNITS
employes,building.,
,i ohm suchimprovementsore net intendederoffered forsole.If,
howevertheavet a burimprovementissoldwithinoneyeaof cogative for thetune of
builder will have the burden of paving that he did not build m improve for purpose of
❑ Las nwnerof the'many.amexcne"clycomrening withlianse4 cantmcmrsoo QTY. PLUMBING PERMIT FEE FLOODZONE APN
amsmct the projec .ce Business and 14afessions Code:)The Contractors
1.i'Irso Lawdncs tapplymamow f rope obuildscrimproves thereon,and PERMIT ISSUANCE.
who centrads torucllprnjectswithaeontmetotis)lic sedpursuantinlhe Contractor's AI TT:R DRAIN&VIN'f-WATER(EA)
License Law. Ffifi SUMMARY
❑ I am eae pt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE T. DF: G_ffS
SANITARY Y N
Owner sDa¢ RI.CHI PTk
WORK N;I NS 'I DEC TION DRAINS-FLOOR,ROOF.AREA,GOND. SCHOOLTAX Y N
❑ 1he by nfOm Itm acenifcat o m xif-iasureaacenifitme of PIXTVRFS-PER TRAP RECEIPTis
Worker. Compass 1 sumnce urs cent anf(Sa.3800.1.ab C.7 which. PARK PEL YN
cave,,tllemP1 e' unr cr tris per 'L GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPTM
PoI' BUILDING DIVISION FEES
Cat pat GAS IA.SYSTEM-OVER 4(EA) PIANCI(ECK FEE
❑ a mm is nereb f w.
❑ cent` copy is eJ th ¢ciiym ctiandivision. GREASEIINDUSTRL WASTE INTERCEPT OR GRADING FEE
CER' ,_ICOFEXE Pr10NFROMWORKERS' GREASETRAP SOILS IEE
MPENS ION INSURANCE
(' is section need not becomple ifthe pctmit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
less.)
Ic ify that in the Perfnrrom ofthe work for which Nis permit is issued,l shall WATER HEATER W/VENT/ELECPR
not crap y any person in any anger so as to become subject to the Workers' PAID
lien Lawsof Culifo . Date WATER SYSTEM/TREATING Date Ree p
Z) z Applicant
Z 0 NOTICE APPLICANT/f.efler making this Carl of Exemption,you should NEWRESIDENTIALPLMB. SQ.IT. TOTAL:
.�. bccomesub oto the Wo ar's Compensation provisions oflhe LaWr Code,you must
x7 fins-Zth Co lywith ch provisions or this permit shellMdamM revoked. BUILDING E
Q CONS'I'R UCION LENDING AG ENCY SETS .E
Z I hereby affirm that hem is a Construction lending agency for the Performance of
the work for which this permit is issued(Suit,301 Civ,C.) ELE IC
lender's Name
U lenders Address QTY. MECHANICAL PERMIT FEE PLUMBIN t
I Certify that I have mad this application and some that Incubi infnrmotion is
cordo, le ra to comply yon County g MECHANICAL
g )ywith all cit and ordinances and atom laws mining to PI!ftMIT ISSUANCE s
huildimg constr ion,and hereby aahorize apresenmtivcsnf this it ty mententpnn the
j altov ract red pmpcny for inepecoion purpeur, ALIHRORADDTOMECIL CONS'TRUCf10 TAX
( agree to save,indemnify and keep harmless the City of Cup[nino against
I'mhiics,judgmctis,contsan nseswhichmayinan way accrue against said City AIRIIANDLINGUNI'TOOI0,000CFM)
in st"tienceefthegranti perrod.
T-S- AIR HANDLING UNIT(OVER 10,00HCFM)
tore of AppNema/Coamem, Data EXIIAUST'HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE IIEA'I'ING UNIT(TO IHI,IIW BI U) Date AI
Will the applicant or future building occupant store or handle hamrdnns material
as defined by the Capr inn Municipal Code,Chapter 9.12,and the Health and Safety I MATING UNIT(OVER 100.000 B1 U) .:
TOT
Cale,Section 25532(x)1
Yes ❑No VENTILATION FAN(SINGLE R'ESID) A
❑
ROILUR-COMPDHPOR 100,0o0BTTD IS UApNCE DATE
W ill theapplicantmrfmurc building acupwt useeyvipmem ordevims which emit b
huraNnus air Contaminants as defined by the Boy Area Air Quality Management NOILL'R-COMP(OVlift IIXI,g10 BTU) 199'sCitrict1
❑Yes ❑No NEW RESIDENTIALMECII. SQ.1'1'. Clt I7��
OF /,u"l�-(�T
1 have read the hazardous materials requirements under Chapter 6.95 of the V `fT I�NO
Celifemia I lcahh&Safety Code,Secdens 25505,25533 and 25534. 1 undersand Nat
if the building does tmmmcmlyhave astlie Neoit is myresponsibilityor. to Codify the
Oce p an of the myuiremems which most be mel prior b issuance of a Cmificne of
Occupancy.
Owner or authorized ugrnl Dam ISSUED BY:
OFFICE
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