28168 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 F//F���� Q
BUILDING DIVISION CITY OF CUPERTINO BUILDING-ELEC (TICAL PERMITSBUILDING PROJECT[DENT IFICATIOY O. n HH
1 V
APPLICATION/PERMIT PLUM N;-MECHANICAL
L
BUILDING DR[S SANITARY NO. APPLICATION SUBMITTAL DAH
IINI!n F' 1/iDy C�NT �OR:S NAME,: LIC NO: N/C CON]ROL#
V
ARCM" :'T NEER: LIC NO: ADDRESS: ElSy S - C V
CONTACT: PIIONE:
QTY. ELECTRIC HERMIT EEE BUILDING PERMIT INFO
BLDG FV1.E PIAMB Mn.
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDEN IAL TOB DESCRIPTION
Iherchy efEnn the lam licemrd underprovisinnsofChapter9(c.mmencingwitM1
u100 Semina 910X).!Division 30 the Bmineasancl Prof,ss....Code.andmy license's in PANELS
FFyw-IclF full haveand cEwt.
Fyrn Locales,Class Lic.# UP TO 200 AMPS
to Q N Dam Chiral 201-1000 AMPS
,7ONZ ARCHITECTS DECLARATION OVER IINI(IAMPS SO.IT.FLOOR AREA $/SQ.b..
07—C landcrstand my plats shall be roll ns public ra' Is.
F.m F-J SIGNS ELECTRICAL
_ Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XC W U 1 hereby difu that 1 on exempt from,he Continental's License Law for the
uta n.y following reason.Sector 7031.S,Business and Professions Code:Any cilyoretumy TEMP.METER OR POLI'INST.
em!!O0; which requires a permit to construct alter.improve.demol iso•or repair any structure
,WYE prior to its issuance,also requims the applicant for such peri I to file a signed statement POWER DEVICES
W C<0 that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
o•XOLL 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ly_y or that he is exempt herefrom and the basis for allege)exemption.Any violation ofOUTLETS-SWITCHES-I'1%TURES
Y Scellon 7031.5 by any upplicamfor a pemtit subjects the applicant to a civil penalty of
< not more loan Eve hundred dol lots($5001.
K__Q ❑ 1,usowneroflheproperty,ormycmployees with wagesaol
s lheirsecomMat
nsion, NEWRESIDENTIALIi.17CfR _SO.FT. SI'ORIP.S TYPE,CONS'rRUCI'[ON
y'j 22 will Jo the work,and the slmenre is not intended oroffered forsale(Sec.7044.Business
and Professions Code:The Contractors License Law does not apply t.an owner of
property who builds or impmvas,hereon,and who docs such work himcifor through his
own employees,provided that such improvements are not intended or offered for sale.If, OCC GROUP RES.UNITS
however,the huildingor improvement is sold within one you ofc.mpletion the owner- T /.
builder will have the burden of paving that he did not build or Improve for purpose of
f91eJ' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,mownerofthe properl sm exclusively contracting with licensedemurxctnes to
consumer the project IScc.90M,Business and',ifcssion,Code)The Contractor's 1 PERMIT ISSUANCE
License Law does nmupply man ovenerofpro,woy whobuilds or impravasthcreon.and l
who ennmucafor such pmjectswi,h acwtrunnr(s)licensed pursuemmthe Cnnusatoes
Lcene Law. gLRR-DRAIN&VENT-WATER(EA)) FEE SUMMARY
❑ mesemptunderSec ,
B&P C for this reason BACK R.OW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
• Owner Date RI!CI?IPf#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMI'IiNSA'I']ON DECLARATION SCIIOOL TAX Y N
❑ I hereby affirm that l haveacertilicam.!coment i.sell-insure,uracenificnte.f FIXTURES-PER TRAP RECEIPT#
ara
Workers'Cmal,rssion lhance or a terrified copy thereof(See.3800,Lab C.)which PARK FEE Y N
eniv,us.11 employees under this peril. GAS- A.SYSTEM-I INC.4 CUTE M- i� RRCEIPTp
Fish,# BUILDING DIVISION IBES
Company
.SYSTEM-OVIiR 4(EA) PLANCIIECK FEE
❑ Corti)eJ ropy is hereby famished,
❑ Cenilied copy ix tile)with the city inspection division. REAS[y1NDUSTRL WASTE.INTERCEPTOR GRADING ITT.
CERTIFICATE OF EXEMPTION FROM WORKER GREA. RAP SOILS FEE
COMPENSATION INSURANCE
rlhissection creditor ovemin leoxi fthepcmrit is foronehundru ars(SE ) SE%_SANITARY-S'i'ORM EA.200T. ENERGY FIJI
of lcsa)
I ccnify that in the Performance ofthe work for which this peril is issued,l sh WATER HEATER W/VENT/ELECTR
not employ any person in any manner w as to become subject to the workers PAID
z Compenatiunlawsof Culifcubc Dec WATER SY.STEMITREATING Dam Receipt#
Applicant
� C) NO'1'ICE'1'OAPPLICAN'I`If.oficnnuking this Gniliw,c of Exemption•you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
I"' y become subject to the worker's Com,ructlim pownutnsofthe Labor Code,you mus,
forthwith comply with such provisions or this permit shall be deemed mvnked. BUILDING FEE
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE:
Z Ihereby affix that there is a cmntfuai.n lendingagency for the performance of �,.. ELECTRIC FGIi
U 0 ,he walk for which this permit sis5ued Ser.3097,Civ.C.) �1
Lender's Name
OF Leader.,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I ccnify that 1 have read this application and state that the above information is
�•' 0. correct.l agree mcom with all cit yo g MECHANICAL FEE
S pd he yardcount taiives of and stain enner.ahn ns PERMIT ISSUANCE
tiZ abovenuncultured construction,and borinspereby ction nectarines.
representatives of this citytoalaruponthe CONSTRUCT ION TAX
Uz aboveunculturedpsave,ind inspection purposes. ALTERORADDTOMECfI.
(we)agree m save,indemnify and keep harlcss City, Cupertino against
y cc
IiabFlities,juJgmems,ttrzsanJexPcnus whichmay in any yaagainst said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
in consluof the gram' •of, pc
/_ O AIR HANDLING UNIT(OVER 10.00x)CFM)
nmia of Applicant/Comm,or )ate EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTID Dae Receipt#
Will the applicant or future building accupam store or handle hmardous material
as debnW by the Cupertino Municipal Code,Chap cT 9.12,and the Ilealih and Safety HEATING UNIT(OVER 100,(03ITT U) T L:
Code,Section 25532(u)1
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
BOB, R-COMP @IIP OR I(K),WO BTU, ISSUANCE DATE
Will taeuemareanturfa a,building by he
nBay equipment unlit Minaes r,hemit p p�
M1wa.J.m air cnntaminwa as defined by,he Buy Amo Air Quality Management BOILIiR-COMP(OVER I(YJ,fX01 Rl'U) P A G
District'!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the havmJous contends requirements ander Chapter 6.95 of the -JUN 12 1995
California Health&Safety Code,Sections,25505.15533 and 25534.1 undersand that
if the building does not currently have a leaned,that it is my responsibility rut notify the y
,accOunnuoi the niculremems which ntml be met prior m issuance of a Certificate of yl I 1 Ur kourrh I INU
Qeeapancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE