28104 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECURICAL PERMrr NO. I O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1
BUILDING PBOJECTIDENI'IFICATION
Blll DING ADDRLESS. SANITARY NO. APPLICATION SUHMI'ITAL HATE
2/610 UNITN LOT# S` ►�'
OWNP NAME: 1'110NE; CONT TOR'S A LIC NO: NIC CONTHOLp
a d 2s Z-73
RCHI'IIECI'/EJGINF.ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
. QTY. ELECTRIC PERMIT Plili
BLDG EL���E��f]]W PLUMIl MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL.
Qaz Ihcteby affmuhnt l Om ficemandandcrpm.isloreof Chapter 9(cmmmeneing With
1V00❑ Secticn](g10)of Divlsbm Sof Oe Bmincss and Prnfaeloms Cocle,malmy license is in PANELS a�T
full form and effect.,
FZ[x] Limmad Class LIC.p IIP TO2W AMPS L�N�•a
m7y Date Cmdmemr 201-I0W AMPS
)ONZ ARCHITEM DECLARATION OVER]1p0 AMPS SQ.Fp.FLOOR AREA $/SQ.FI',
O Z 1 understand my plans shall be used as public records. _
FQN .,4 Licensed Professional SIGNS ELECTRICAL. _
1'K�< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
OyF I hereby effort that 1 am exempt from the Contractor's License Law for the
tu3am f�lk—ingreason(Seninn](DIS,liminess and l'mfessimns Code:Any city nr county TI?MP.ME'I'HRORPOI.1?INS']'.
�°'O� which requires a Permit toconswa,alter,improve,demolish,ordepairanystmeture
prior to its issuance,also requires the applicant forsuch promil to rile a signedswtemcm POWER DEVICES
O0 than he lx l imatedpuraonnn thepravisiancnflhu Conwemrs Lima,.Law(Chapter
L cyoK 9(commencing with.Smlmn]00Eof Division 3 ofthe Busincssand Professions Com) SWIMMING IDOL ELECTRIC
X a VALIIA'TION
yFF..)Zy
or lie7031.emptnyappomand the baspermitorthcasegedexemptioa. civilp malty of
�Z4 Section LS by any opplicumfor upennit subjects the npplicanna acivil penalty of OUTLETS-SWITCHIS-PIXTIIRES
not mare tbnn five hnndrrxl dollars(ESINI),
C m ❑ I,aowmroOhc rat t ycmP Y g pensaiion, NEW RESIDENTIAL HLECTH S .FI'.
p Mry,orm erred orofwa eorsalei(Sec.cora Q STORMS 'TYPE CONS'TRUCT'ION
W 3— will do work,and r: stricture oC."I Esnot is Limule offered does Out (Sec.] an Business -
antl Pro1'nssions Cadld—at no.ca,hemnr's l.lcroso Law docs not apply tO an owner of
proownenywyees,pdsvi&dchep rvsuc[iiemn,nal cments notihwmkoroffe form gh his
hncmr,thees,p oritprovehEmpmvementhinneyear Jetimplecrcd the le.If,owner- OCC.GROUP RCS.UNITS
weveOOeavbuilding icor improvement 01 cmentissold he
not ba Id ort improve n.
theoric r- T �a
builder will have the burden ol'proving that he did not ba Id or improve for pupvmm of
sale.). - -
❑ I,as nwnernOhe pmpeny,:unex<lusivelycommetingWith licensed commemnm QTY. PLUMBING PERMIT PER ILOW ZONE Apry
Convruct the project(See,7(44,Business and Professions Code:)no Continuants
License Law does not apply um unownerofProperty who builds orimpmvesthemon,and PERMIT ISSUANCE
whocontmms nmsuch Projects with artatraclnAa)limmeal purmannnthe Contractors ALTER Law. WATER(HA) FEE SUMMARY
❑ 1 am exempt under Sec. H&I'C for thio reason BACK FLOW PRO'1'ECT.DEVICE OLD 8_1 OF PEES
�OWrerDate SANI'1'AHY Y N
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX V N
❑ Iherchy uflirm thatlhavc acmitir to of mnxmmsel
inside
FIXTURES-PER TRAP RECEIPT
employees
nlmumnceora cenifieJ copy thereof(Sx.38W,Lab C.)which PARK PER Y N
covers all employee's unJenhis pcnnit. GAS-EA.SYSTEM. INC. OUT LETS RECEIPT N
Panic,q BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cenifiedcapyisherchyfuorishad.
❑ Cenifed copy is fled with the city inspection Jivisimn GRFASEJINDUSTRL WASTE INfERC1EP1'OR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FIA?
COMPENSATION INSURANCE
(This sectionnerd not he completed ifthe permit is t'onn.hundred dollars S 100)
or less.) SI3WIiR-SANITARY-STORM PA.2001-1. ENERGY FEE
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR '
not employ any poem. in mry mnnne,in,as in beconm subject to that Workma' PAID
z Compcntnion Lawsof Cmifsoria. Due WATER SYSTEW BEATING Date ReceiplN i
O O Applicant
y� NOTICE TO APPLICANT:I L after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.
F lmmmc subject the Worker's Compensation provisions of the Labor Code,you most
TOTAL:
forthwith cora with such pe
� � comply provisions or Permit shall be AeemeJ revoked, BUILUIN FF.F
W
F CONS'I'RUCTION LENDING AGENCY, SEISMIC FE.
5 I hereby inform that there is a construction lending agency for the performance of
V Or the work for which this permit is issued(Sm.309],Civ.C.) TOTAL: FLELTRICIEE
w P Lenders Nome
Lender's Address QTY. MECHANICAL .2M11' }"v PLUMBING FEE
J ]«nify that 1 have read this application and state that the above information is
coMEC NICAI.Flili
correct. (agree mc�mply with all city and county ordinantteand smrelaws rtlatingm PERMITISSUANCE
building constmetinn,and hereby anthoriro repreeowvtives oDhiaehy counter upon the t--
V Z above-orentlaned property for inspection parpsms. AI:F'ER OR ADD MECH. CO R) ION'AX
(Wel agree m save,imdem 'fy and kxp harmless the City of Cupertino against
O 'ne',
gmcna,c."'am peeves which may in any way accrue against said Ciry AIR HANDLIN UNIT(TO 10.000 CFM)
c'orni'ng' oaf Ni' crdmit. !
AIR HANDLIN UNIT(OVE ,1100 P ) x
:ignaturm of Ap ((norm/Conunmor Data EXHAUSTHOOD( UCq
PAI
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOq BTU) Date Receipt N
Will the applicant or future building occupant stere Or handle h:vmdous material
as defined by the C,satlno Municipal Ccale,Chapter 9L2,andthe lleahh and Safety HHAI'ING UNIT(OVER 10),X
BTU) TOTAL:
Coda.Section 25532(q]
❑Yes 0 N VIRGHLATION FAN(SINGLE EISI
I
BOILER-COMP(311P OR 10EM 1DTD) 4S tb(]H DATE
Will the epplicantnrfmumbuilding xcupmtuse equipinemnNevices which emit II !J
huaidous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OVER 1011.000 BTU
District] ) SAY 17Q
❑Yes ❑No NEW RESIDFNTIALMECIL SQ.FI'. ) 1J��
1 have read the hamrdnus materials requirements under Chapter 6.95 of the C/I J
Colifornla Ilealth&Safety Cmlc,Sections 25505,25533 and 25534. 1 understand that
if the building fres oat cordially have u mnan6 that it is all re.ponsibility to notify the
circular,of the requirements which must be met prior to issuance of a Cenificate of
Occupancy.
Owner m umhodud agent Dam TOTAL: ISSUED BY:
OFFICE