28172 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.xiTCTRICAL PERMIT NO. 28
172 72
BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING-MECHANICAL. �XJ 1/ L
BUILDING PROIF.C'LIDEN'1'IF7CA'I'[ON
BUILDING ADDRESS: '\�`y�- ` - SANITARY NO. APPLICAII'ION SUBMI'TALDATE
��✓�� �` 1 1�
ON]I'll LOT It a 5
OWYaSNAMC: `J . 11 PHONCE: CO RACTOR'S NAME: LIC NO:
'rya N ZS G cN/C CONTROLIf
iRCHIT1iCl'/INGINH'R: LIC NO: ADDRESS: - SG❑
17-2-41 eokb 9S
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT� PL MECH
PERMIT ISSUANCE
LICENSED CONTRACfOR:S DECLARATION APPLIANCES-RESIDENTIAL ��,nnn
py.Cz (hereby affirm that 13 of
usinss and
Professions
Code,
(commencing se wish
00q Section V000)ofect. venJof the Business antl Professions Code,antl my incase is in PANELS IIC/J�r�1y
TUU full fine and Cloncffect.
FZm License Class Lic.p UP T02IX1AMP5
I1=oi, Dam CmmmcD 201-10110 AMPS SQ.FI'.FLOOR AREA Ii/SQ.FT.
z O vfz1r ARCIIITIiCfS DECLARATION OVER 11X111 AMPS
O Z'-'I] Iinlannnd my plans slot l list used ria puhl at retracts.
C W SIGNS ELECTRICAL
<Y�M Licensed professional
E%ci OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
. OaF 1 hereby affirm that 1 on exempt from the Contractors License Law for the
W 3wtn following return.(Section 1031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which rotp ims o permit It construct,alter,improve,demolish,or repulr tiny structure
rn}� - to its issuance,also re the applicant forsuch Permit file a signed statement POWER DEVICES
yts�� prior ,macs pp drmri en
r.COp 9homhe larem.,dpunuann700finWsionsof the Centncmr's and (Chapter -
a'ao� 9(commencing with Sation]01N))ofDivision3ofthe Business end Profasioro Code) SWIMMING POOL ELECTRIC VALUATION
yKj r^y
or that he is exempt herefrom and the basis for the alleged exemption.Any violmlonof OUTLFTS-SWITCHES-FIXTURES
4 Section 1031.5 by any 3'1'.ml forupermit subjects theapplicannovcivil penaltyof
tit more than Ove hundred dollars(5500).
A NEW RESIDENTIAL ELCCfR 19.
o n❑ Las owneron he mnpoly,or my employees with wages as their sole compensn[ion, -SQ. STORIES TYPE CONS'I'RUCI'ION
will do the work,and the structure is not intended or offered formic Ses.]1144,Business -
and Prolessiuns Code:The Cnmmcmta License Law dMs not apply a+an owner of
property who build.or ineprove,donern,and who dceaeuch work himxlfor through his OCC GROUP R65. NITS
own employm employees,providedthat such improverrentsrnot in[erdedoroffered foraale.If,
however,the building or improvement is sold within one yeanfcompleiondhenwner-
balkier will have the burden of proving that he did tint build or improve for purpose of
sale.).
❑ I,as owner of the PropenY•mn exdusivelYrommttinB withlicenud mntnaors to QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Profnsitms Code:)Ibe ComnctolsPERMIT ISSUANCE
License law does not apply man owner of propcny w ho builds or improves eon,therand
who contracts for such projects with a contentions)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 nm exemlpt under Sec. ,B&P C for this rensnnOUTSIDE.ELLS
BACK PLOW PROTECT.DEVICE -
SANITARY Y N
Owner pate DRAINS-FLOOR,RGOP.AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihertbyaffirm that l have acerifieste ofcoment to self-imure.ora carificateof FIXTURE'S-PER TRAP RCCLIPI'p
Workers Compcnution Insurance or a certified copy[hersof(Sce.3800,Lab C.)which PARK FF.F. Y N
covers all en Ie cc's code, is mrmit. CCCIPTp
P Y GAS-I:A,SYSTIi -1 INC.N4 ,BTS
Policy k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM- 1' PLANCHECK PER
❑ Cenifiedcopyishembyfumished.
❑ CerifeA copy is fled witlnhe city inspection division. GREAS P S$EINTERCEPTOR GRADING FEC
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE A SOILS FEE
COMPHNSATION INSURANCE
(This section..door be completed lithe permit is fervent,hundred dollars($100) SEWHR-SAN ARY-STORM EA.20011 1'NHRGY PHI
less.)
I certify that in the performance oflhe work for which this permit is issued,I shell WATER HEATER W/VENT/P.LELTR
not employ any person in any manner so as to become subject to the Workers' PAID
CompensationLowsvef Celifemia. Data WATER SYSIEWORETING Data Receina
Uz Applicant
U NOTICHTO APPLICANT:IL after making this Certificate of Exemption,you should NEW RHSIDEN"PIAL PLMH, SQ,IT.
OTA(,:
Z
bechwithc subject Worker's Compensation is prnvisinnsoh theLaborCooked. muss BUILDING FEE
forthwith comply with such provisions.,,his permit shall be deemed rcvnked.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.Z 1 hereby affirm that there is a construction lending agency for the performance of
U Q the work for which thin pvarit in isaued(Sec.3(19],Ci v.C.) O' ELECTRIC FEF,
Lender's Nene -
OU U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I ccnify that 1 have read this application and auto that the above information is MECHANICAL FEE
RW. cerreCl. lagrce to comply with all city vend musty ordinances end s[e¢Ivws rtlatingm PERMITISSUANCE
07
V) building construction,and hereby umhnrize representatives ofthiscity to emeruPon the CONSTRUCTIONTAX
U 2 above-mentioned property for inspection purposes. ALTERORADDTOMCCII. -
(We)agree It,save,indemnify and keep harmless the City of Caperino against
liabilities,jud,ancon, maind expenmawhich may fruity woyaecrueug sl said City AIR HANDLING UNIT(TO 10,11(111 CFM)
in stye Xe of the gnntin8 of(his Fermi 6 �
/7L�J /N`I AIR HANDLING UNIT(OVER 10,000CFM)
Ap�X/ EXHAUST HOOD(W/DUCq
ISignamre of Ap r/ mnc[nr Dale PAID
HAZARDt1USMATERIALS DISCLOSURE. HEATING UNIT(TO 101,000 BTO) Date Receipt M
Will the applicant or future building occupant store or handle hazardous material IIIATING UNIT(OVER 100,1X10 BTU) TOTAL:
as defool by the Cupertino Municipal Code,Chapter 9.12,and the Iholm and Safety
Cade,Section 255320e01 VENT
13 Yea ❑No ILA'I'ION PAN(SIN(SINGLERCSID)
ISSUANCE DATE
A
Will thenppllcamorfaturchuilding nccupanwucyuipmemmBOILER-COMP(3HP OR 10,000 BTU) UANCE
�ievicen whichemi[ r, A O
hazardous air comaminants as defined by the Bay Arca Air Quality Maaagcmrnt BOILER-COMP(OVER 100,IITI)BTU) r
District?
❑Yes ❑No NEW RFSIDENi'IAL MEC11. SQ.IT. JUN O 17 O 1995
1 have read the hazardous materials Tcyviremems under Chupmr 6.95 of the yFY`'
California I leahh&Safety Code,Sections 25505,25533 and 25534. 1 understand that y
it the handingdocs not currently kava a Ceram,That it is myresporsibllily m CI lmodify V 1 Uh L;UPEHnhin
occupant of the reyuiremenls which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Data T ISSUED BY:
OFFICE