28304 (2) i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD: C,-ELECTRICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 28304
BUILDING PROJECT IDENTIFICATION
BUILDING p�S� ` n ^� w 1 ,I P� SANITARY NO. APPLICATION SUBMITTAL DALE
UNIT LOT it 5
WNI
PHONE: CO A E7
: LIC NO:
t iN/C CONTROLp
sRCHITECT/ENGINF.ER: `
LIC NO: ADDRESS: Ga \ ❑
CON'TAGf: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG PLUMB MECH
PERMIT ISSUANCE �f IO/
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L� JOB DESCRIPTION yP�
y04 IhcrebyadDivisthat l amlice Businderpmvitionsofal Code.
9(commecense with
00 fullSesaima
rceandofecivisian3of the Business and Professions Code,and my license is in pppfELg
License
eities t. � I
Fye License Class Lic.p UP TO 200 AMPS
rn5y Date Contmcor 201-IM)AMPS
g- SQ.PT.FLOOR AREA S/SQ.IT.
OZ-0ARCHITECTS DECLARATION OVER IOW AMPS
O Z_❑ I understand my plans shell be used az public records.
I:.
4!Z W I SIGNS ELECTRICAL
q' a Licensed Professional
L. 41 OWNER-csc.,i 5Rm the CoATION SPECIAL CIRCUIT/MISC.
ippiS5Oa tVt-. 1 hereby n.(Se tiro 1 ere excmpi from the Convenors License Law for the
t++34tn following reason.(Section 7031.3.Business and Professions Cade:Any city orcounty TEMP.MLTER OR POLE:NST.
t LL which requires a permit to construct.Nor,impose.demolish,or repair any structure
Y� prior to its issuance,also requires the applicant for such pmnivafileasigned statement POWER DEVICES
O that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELF"C1 RIC VALUATION
m_rn or that he is escopnhafsem and the basis for dartlleged exemption.Anyvialom of OUTLETS-SWITCHES-FIXTURES
k Q Stxtian 70JL3 by any ePPliant for a permit subjcets the epplicsm to a dvil penalty of
t] nm more that five hundred dollars($50E. NEWRESIDENTIALELECIit _SQ.FT.
[II,usownerofthepropny,ormyemployeeswithwagnatheirsolewmpensaion, STORIES 'I'YPECONSTRUCDON
a will Jnthework.anti thennicmrefinal rmendedaroffacal fim,ile(Sea]044,Business
and Professions Code:no Contractor's License law does not apply to an owner of
property who builds or mr ovin Nermar.and who does such work himulfor through his
ovocariployces, such impmvemenissre not intededoroffcarl(oracle.If, OCG GROUP RFS.UNITS
however,the buildingor improvement is sold within one yearofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sine.).
❑ n,es ownernfthe popery,emexdusivenycontracting wiNliunsW rontractarsm QTY. PLUMBING PERMIT FEE n.00Dz N APN
convect the priject(Sec.7044,Business and Professions Coded The Convectors
License lawdusnotapplym an ownerofpropmy who buildeor improves Nccon,and PERMIT ISSUANCE
who contracts for each projects with a contracmr(N licensed puma:mOo the Contractor's ALTER (IA)
License law. FEE SUMMA
❑ 1 em exempt under Sw. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARYV N
Owner Date DRAINS-FLOOR,0.00F,ARPA.COND. RECEI
p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have o certificate ofconsent to self-insure,or a certificate of FlXTURLS-PER TRAP Ep "it
Worken'Compevation In umnw on certifiedcopy Nereof(Sec.JBW,Iab CJ which — PARK FEE Y N
covers all employees under Nis permit. GAS a FA.SYSTEM.I INC.4 OUTLETS' RE :PTp
Policy 8 7. BUILDING IS-ION FEES
Company r tete, GAS-FA.SYSTEM-OVP 4 � PLANCIIECK FEE
C1 Certified copy is hereby furnish W.
❑ CertifiW wpy is filed with the city ir¢pection disisioti. N U L A NTERCEPTOR GRADING FEE
r
CGRTIFlC INN MOMWORKERS'
O1� ARPA q Iypp—r Yrl SOILS EE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for unehundreddo ars(SIW) '' SEWER:SAM Y-ST .20l ENERGY
m how.)
I certify that in the performance of the wok for which thio permit iii ,,Ishall r
.of employ my person in any ounce,are us m become subject to the Workers PAID
z Compensation Lawsaf California. Date SY&TBM/1'MfATING ate Receiptp
Applicant
z0 NOTICETO APPLICANT:If.after making this Certificate oflixamcould NEW RESIDENTIAL PLMBE SQ FT. TOTAL:
(- fn become subject to the Wohers Compensation presidents ofthe Labor Cade,you most
a Ij forthwith comply with such provisions or permit shall be deemed revoked. BUILDING
W C• CONSTRUCTION LENDING AGENCY SEISMIC FE
z
^� 1 hereby affirm that there is a construction lending agency for Ne performance of ELECTRIC E
U O the work for whim this pend is issued(Sec.3007,civ.C.)
Lender's Name PLUMB: FEE
U Lender's Address QTY. MECHANICAL PERMIT FEE
1 scop,that I have read this application and and,that the above information is
coma. I agree tocomply with all city and county ordinances and state laws refutingto PERMIT ISSUANCE. MECHA ALFHE
buildingcortsuvction, dheaby auRroria representatives ofthis city oenterupon the CONSTRUCTIO AX
L) 7 eMvemc m pre v yfm ins pion purpoxs. ALTER Oft ADD TO MECH.
F7 (Wal eg to ,indeiif ad keep harmless the City of Cupcnino against
liihiliti ,judg ere,c ste pe es which may in any way acerueigainst said City AIR HANDLING UNIT GO 10,000 CFM)
c ft a oft permit.
-� AIR HANDLING UNIT(OVER 10.000 CFM)
Signa App tc n/ omracmr Date EXHAUST HOOD(W/DUCI]
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date R ipt p
WillNe epplicsm orfumrc building wcupentamm or herdle hevrdoua meteriN HEATING UNIT(OVER 100,000 BTU) TAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda,Section 25532(N1
❑Yes ❑No VENTILATION PAN(SINGLE RBSID)
ISSUANCE DA
LWill NeapplicemorfdurcbuiMingowup:mtuseequipmentordeviceswhimcmit BOILER-COMP(JHP OR IM."BTU)
wmrdons air communication as defined by the Day Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Pi Ll
P DistficO ❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.FT. AUGWO 1995
limitations1 have read the limitations materials requirements under Chapter 6.95 of the
California Health&Safety Cad,Scoot.15505,25533 and 25534. 1 understand Nat ClIY Ur xwr )if the building does not currently have a tenant,that it is my responsibility to coli fy the
occupant of Ne requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or int d o iced agent Date ISSUED BY:
OFFIC