28283APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO BIILDI (:-ELECTRICAL
APPLICATION/PERMIT PLUMBING -MECHANICAL .
BUILDING DIVISION BUILDING PROJECTIDENTIFICATIOF
PERMIT NO.
Q n Q
o G o
BUILDING ADDRESS:.
SANITARY NO.
APPLICATION SUBMITTAL DATE;
UNIT# LOT If
OWN 'RS NAME: PHONE:
`J -U
CO ACTOR'S NAME: LIC NO:
O x4 v5
NIC
❑
CONtROLp
ARCHI'IECE(ENGINNEEER: LIC NO:
A ®S:
G
CONTACT: PHONE:
QTY. ELIiCfRIC PERMIT FEE
BUILDING PERMIT INFO
BhUG IiLLPLUMB MEfl
PERMIT ISSUANCEr11��/
Ze
❑C
❑
LICENSEDCONTRACTOR'S UL .ARP.I[ON
I nerchy uffinn thm I nm licensed underpr.visinnsnfChup¢r 9 (commencing wish
APPLIANCES- RUSIDENTIN'
JOB DESCRIPTION
PANELS
Section 7000)of Division 3 ofthe Busimessand Professions Ctde.and my license is in
A
full and
force a
Licensee and Lic#
UP T0200 AMPS
�
Date � O-� 7a-A�- �n� l Convector
TECTS CL RATION ��
1 understand my plans shall be used as public records.
201 - RMAMP5
OVER 1000 AMPS
SQ. FT. FLUOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contactors License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
_
which requires a permit to construct, alter, improve, demolish, at repair any structure
prior o its issuance. also requires the applicant for such permit o file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Comrunor's License Law (Chapter
9(cm cing w ,In Sectionns ]000) of Division 3 of be Busines,and Podfir,sioCode)
SWIMMING POOL ELECI RIC
VALUATION
or that iv exempt therefrom mid me basis for the alleged exemption. Any violation of
Section 9031.5 hyany applicant for a permi... bject,the upplicann. avM]pcuali,of
OUTLETS - SWI'ICI I ES - FIXTURES
not more than rive hundred dollars ($500).
[II.asownerofthepmp rty,ormyemployeeswiihwagesaslhelnoleasmpen.satins,
NEW RESIDENTIAL ELEC'1'R SQ.FT.
STORIES
TYPECONS'1'RUCHON
will do Ne wtsrk,.ed lee,tracmm is not Intended oroffcred forsake(Sec. ]1144, Busines
and Professions Code: The Contractors License Law does not apply to an owner of
progeny who builds or improves lhemorand whodcessuch work himselfor through his
own employees, provided Th d ooh improvements. not intcndcdtroffctrd forsale. If.
OCC GROUP
RES. UNITS
TOTAL:
however. the building or improvement is sold within one year.fcompletion.the owner-
builder will have the burden of proving that he did not build or improve for pvmuse of
QTY. PLUMBING PERMIT FEE
ale')'
❑ Las rofthepmpcny,am xclusivelyemn ctingwithlicenx contractorsto
FLOOD ZONE
APN
remtrua the project (Sec. 7044, Business and Professions Cade:) The Contractors
License Lovedoes not apply to a.ownerofproperty who builds or improves thereon,and
PERMIT ISSUANCE
who contracts fnrsuch projects with acontraangs) licemed pursuant m the Contractors
License Law.
ALTER - DRAIN & VENT'- WATER (EA)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C fur this reason
BACK FLOW PROTECT. DEVICE
OUTSI Ong
SANITARY N
RECEIPT#
Owner Doc
DRAINS -FLOOR. ROOF, AREA, COND.
WORKMAN COMPENSATIONDECI,.4RATION
SCII001.'1'AX Y N
hereby affirm shall have CCniBCatc of consent In yclLin,urc, orncertiricme°f
eorucertifiW copythereof (Sec 3XW, hob G)which
oe'.11
RECBIPI'#
FIXTURES -PL'R TRAP
PARK PCI: Y N
vomo,rrd,onler this
en all e+rydnyce's under this permit
Policy# w� �-3�a-7
GAS - EA. SYSTEM -I INC. OUTLETS
RECEIPT' #
tlU1L IJIVI'O iF:S
CnmyRrrrr�� ! O
GAS - EA. SYSTEM -OVER 4 (EM
PIANCIIECK FEE
�Ccmficd copy is hereby famished.
GRFASFANDUSTRI. WASTE INTERCEPTOR
GRADING FISH
❑ Cenilied copy is Bled with the city inspection division
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS ME
COMPENSATION INSURANCE
SEWER - SANITARY - STORM PA. 200FT.
ENERGY FE
(Inti, section mood not becompleted iffle pemtit is form., hundred do]]. (SIM)
or less.)
WATER HEATER W/VF.NTSE'LECIR
I cenifytbnt intbe perhomunce of the work her whichthis permit is issued.) shill
nm aemploy any person in any mnm ner so as to become subject the Workers'
PAID
WATER SYSTENb TREADNG
Compresutina Lawsof C.Ilfmnlu. Date
Du Receiptif
AplicantNOIICBTOAPPI.ICAN'r:ILaftermakinglbisCenifiwtenfExemption,youshould
ZA4L
NEW RESIDENTIAL PCMB. SQ. FT.T
become subject to the Worker's Compensation provisions of the Luba CW e. you must
fnr0wi th a ,ren, with such provision, .,,his permit shall be dceined revoked.
BUN ING FF.Ii
SEISMIC ;
CONSTRUCTION LENDING AGENCY
1 hereby affirm that IM1ere i,. construction lending agency (,,,,he performance of
the work for which this permit is issued(See 3097, Civ. C.)
TOTAL:
ELECTRIC FTE
Lenders Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FIT
Lender', Address
1 ecnify that 1 have rod this application and state that the above information is
rrect.Iagret to comply with all city and county ordinances and state lows relating to
PERMIT ISSUANCE
MECIIANICAL. FEE
building construction, and hereby auNoma represenutivesof this city tear upon the
abovcmentioned Property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agr,e to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmena, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO I U,IXU) CFM)
in consequence of the gating of this permit.
AIR HANDLING UNIT (OVER 10.000 CFM)
EXI IAUST 11001)AV/DUCT)
PAID
Signature of Applain4Cnnlrarme Date
HEATING UNIT('1'0 100,000 B U)
HAZARDOUS MATERIALS DISCLOSURE.
Date jlecei
Will the applicant or future butldin occupant store or handle harurdous material
ns Aclincd by the Cupemon Mum oda, Chapter 9.12, unJ tM1V llvalth and Safety
AL:
HEATING UNIT (OVER II)fl,(IW I;TI])
VENTILATION PAN (SINGE,]; RI?SID)
Code, Section 25532(0)1
❑ Ycs LfN
ISSUANCE DATE
Will thea applicator or future build! ruses t ordevicts which emit
pp cupan yuipmcn
hvardre, air c.nu mraxrR as sed by the Bay Area Air Quality Management
District/
BOILER- COME (311P OR IW,000 BTU)
P
W 1 ll
410
V
BOILER -COME (OVER HKI DW BTU)
NEW RESIDENTIAL MECIL. SQ. FT.
❑Yes 0 N
1 have read the hassdous mmerids "toraments under Chapter 6.95 of the
Califomw Health & Safety Code. Sections 25505, 25533 and 25534. I undersand thea
/n i]
^ r V 'ar Fj 1
�1' 11915
if the building does not urrently have a tenant, that it is my responsibility to notify the
, wren ma,t et prix, m ia,aa.ee of rnreeae of
tie
�UI=EN
1 )
TOTAL:
Own br Admitted agent to
ISSUED BY:
v OFFICE