28488 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 284,88
BUILDING PROJECT'IDENTIFICATI
BUILDINGADDRESS: SANITARY NO. AP ATIONSUBMHTALDATE
X00 fj Sv 14 1 '"^ b
O /ER'S YHO ,. )MeyR(�CI'OR'S NAMGE: /^-1 LIC NO: -
v{/ �(,/ •I..li G.TAfY WNTkLa�CfD7��Z 'NC CONTROL#
ARCH
CONT Px
TECT/ENGINEER: LIC NO, ii)D„io OC l u� 1' K �
' CONTACT: • � ONE: /� � -AC BUILDING PGRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) PLUMB x
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�OZ with Section 7000)of Di vision 3 of the Busiattliu l Pndesxians Cndc,undmyhcenscis - RESIDENTIAL
O t PERMIT ISSUANCE —�
W Lite
end effect. '��
�U� License Class Liag ❑SFDWL ❑PLUMBIN RE-PIPE Date Cnnlracmr APPLIANCES-RP.SIDENTIAI.
�Za ❑ADDITION ❑PLUMBING RE-PIPE
I..7,� ARCHITECT'S DECLARATION PANELS ❑MUL'D-UNIT [I STRUCTURAL
Z O 1 undemm�d my plans shall be used i s public reemi MODIFICATION
OZ UPT02MAMP5'
4^Fq Licensed Professional El INTERIOR [I CHIMNEY REPAIR
yx, OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
yyy�
gm
M 6 I herehy affirm that I ant exempt from lie Commnor's Llcenso Law for the OVEN 1000AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
W
0'U
aU following reason.(Section 7031.5,Business and Professions Cade:Any city Or county ❑OTHER
which t to conswct,alter,int owe,demolish,or repair un .,In
SIGNS ELECTRICAL
requires a panni PY s
no.,,,it,lsso.nce,.lsore9uireslhe...I esm fim,a,h perm..lilcusigncd sedcownt SPECIAL Cl RCUIT/MISC.
} Nat he is licensed pursuant m the provisions crane Cormuna's License Law(Chapter9
�0 (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.MEMR OR POLE INST. COMMERCIAL
6 e' Nat be is wunapl the donna and the hasix for the alleged exemption.Any virl rian IO
of ❑NEW BLDG/ADDITION ❑DEMOLITN
n
m Section 9031.5 by any appli for a perom subjects are applicant e applicano.civil Penalty Of POWER DEVICES FNANT ❑FOODSERVICE
1g..., room than Gve hum dollars PROVEMGNT
ESCQ ❑ I,asowncndthep olamy,ormy mnpIn with wages as their sale compensmion, SWIMMING POOL ELECTRIC,
•CZCZ GCGC will do the work,and l esouclure is not marine flared for sale(See 7044,Business ❑OTHER
W and Professimue Cod :The Conwcmb License sat apply to an owner ofETS-SWITCHES-FIXTURES
a'3 propeny who builds it intpmw,,thereon,send who does in work himself or through
his own employees rovided that such improvctmfs'hic n imended or offered for NEW RESIDEMIAL ELEC3'R SQ IT.
saIs,ILhoweveeth huilding orimprovemem is m)tl'within nn a rofcompictusm,he - SQ.FT.FLOO AREA _ L FT.
owner-builder will avolhemolenofpmvingth, In orimproveforpur-
pose of ade.). : 21
El I,as owner n e"'arty.am c.cl.sivc sling wi licensed conduct,0 t T
construct Ne pn est(Sea 9044,Business an c.f ay(ons Co •;7 TM10 pnan umrs -
cemaslaadoc. ofapplytoonownerof 116 builds n improves Recent, id QTY •PLUMBING PERMIT FEE
whocontrects t uch projects with a co densed rsuant to the Cnm. is"
License Law, rs r e, PERMIT ISSUANCE
❑ Toro exam IunderSm. :/ ,B&PCfar rcuson
s• AITE R- AIN&VENT-WATER(LAJ NALUATI N owner nate
RKER'SCO ON DEC a,LAderm
.ARA9*10 11 BA: P ECT.DCVICE
Ihereby off oder pcnehy itFy eo( efollo gJeAamtieAr. ,J
I have and will mains aCeri are id me ms if-ins fin W..kcr'x oro t DINS- ,001CROOPAREA,COND. STORIES 1'YPCCONS'fRUC'I'ION
sation,as provided for M1y ion 3TX'lithe I n ante,f r the pedo n c
work for which this perm it is is. d. �/ FXI E.S-PERTRAP
1 have and will muimtin Works' Co pensmi11n I n p by Se
39W ofthe Lab11r Code,for the Farm eofinewo Rinse h toil isi\i• - G -EA.KYSTEM-1 INC.40UTLCTS
My Workers Compensation Insurance m c• and Pill y number OCC.GROUP APN
Carrier. GAS-BA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GRCASEANDUSTRL WASTE INTERCEPTOR
NV
(This smtion need not M:cnmplmcm
at if the peit is for one hundreJ At ars(511 BUILDING DIVISION F ;S
or less.) GRI7ASE TRAP
PLANCHECK FF.F.
certify thatimhe perforation clans work fe which Nis annuls issuN,Ishall
;0."*
npiny un permn in tiny 'arms,111.11.bcoa x he agYf ye yVoycy:C SEWER-SANITARY-S"ITIRM EA.200 FT,
y u j nmpcn- ENERGY FEE yLk
O sstrum L y a WATER HEATER WNENT/ELECTR
PP GRADING PER
tiNOTICE. AI IC NI. Luft cnificure of Hxcialson,you should WATER SYS'TGMfTRGTING '
abooms subject to the Worker's Co.,.e"o provisions of Ne Labor Cala you must SOLI S FEE
Gt7forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING dingaAGENCY NEW RESIDENTIAL PLMR. -SQ.PI'. PAID
1 herebynffrmthetmere iso d(See i30lending agency for the perfilrmancc of Receipt#
W rr he work for which mis permit is issued(Seo.31199,Civ.C.) ,
0 U 1<mderx Name TOTAL.
fS.l Lenders Address TOTAL: IL
0. certify That I have reud ibis.pplicmion and smte that ahs uhnvO infonpadnn is RUI G ;E /a
V) correct.l agree to comply with all city and county ordinances and state laws relating 1. QTY MECHANICAL PERMIT FEE
U 4 building construction,and hereby authorize represeoatives of this city to enter upon the SEISM EF.
above-nmntioned property for inspeJWILLCO
PERMIT ISSUANCE(We)agree til saveInde nies heCiO.fCupcmn.r,mum ELECTRIC FIE aroy accmeagainst said City ALTF,R OR ADD TO MECH.incoraCil of thegmntin n thPLUMBINGAPPLIC NTL. ERSI. D. A 'fR ALL NON-POINT AIR HANDLING UNIT GO 10.000 CPM) '
SOURCI EGUL TIONS, 1110 IC LFEE
y/7ry AIR HANDLING UNIT(OVER lq(IBOCFM) y NSiHU TION TAX
ao Signature pp lean o 1.r .[)ate EXHAUST GOOD(W/DUC1)
HAZARDOUS MATE ,. DISCLOSURE OUSING ITIGATION FEE
Willthcopplienm orfumre building occupant samemiandle hazardous marnid HEATING UNIT(TO 11X,000 BTU) y a
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532m)1 HEATING UNIT(OVER 100,000 BTU) (�(/
❑Ya ON. VENTILATION FAN(SINGLE REBID) PAS
,V Data Receipt#
Will the air coma or allure building y the B use cu Air antQu lity Management
which BOILER-COMP(3HP OR 100,000 BTU
emitict? us air comaMnants as definW by the day Amu Air Quality Manegemem )
District? T
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
(have read N<h.rardops maariuls reyuimnrnts under Chapar 695 of the C.li- AIRCONDITIONER ISSU NCEDA
Temic Health&Safety Code,Sermons 25505,25533 and 2.5534.1 understand that it the NEW RESIDENTIAL.MECH. SQ.FT.
building does not currently have a lemon,Nm it is my resgmsibility to purify the occupant
of the aquirrmenas which must he met are to issuance of.Certificate of occupancy.
Ow•nerorauthonu .gens Duo T ISSUED BY:
OFFICE