28402 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /1O /I4,OZ
APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING DIVISION LBUILDING PROJF,C"f IDENTIFICATION
BUILDING ADDRESS: ii�� SANITARY NO: APPLICATION SUBMTIT ATE
1 7 La l N� UNIT# LOT If
OWNS NA E PHONE: CO/ry7RACfOR'S NAM LIC NOif k4a IN : LLL ill...
f LOCI I� Q P!J: f/ N)C CONTROL#
ARCHITECTRiNGINI �R: •LIC NO: ADDRESS: ❑
ltd c' e
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
U (A e 6 C f PERMIT ISSUANCG DL ELECT PLUMB M[CII
III J� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
mwz I hereby affirNut lam licensed underpon
rovisis.fChapter9(commencin,nift TOB UESCRIPI'ION
m
[ 00 Section 7100)of Division 3 of the Business and Professions Code,and my license is in PANELS 1
al's
fail ft"'c upJ oll'em ) Z
Fz� Licena Cl:tss r ?'C` Lic.# Lx�_J29 ' UPT02W AMPS
rn7y
Date 1T-13'�Comrunor M UNx� ](11-HXX)AMPS rA IV If
FyZ_ ARCHITECTS DECLARATION OVER IM AMPS SQ.FT.FLOOR AREA $(SQ.I'1'.
Z O
OZ�oe O 1 understand my plans shall be used as public records.
F,m F m SIGNS ELECTRICAL
<Y F jj Licensed Professional
w,w< OWNER BUILDER DECLARATION SPECIAL CIRCUTOMISC.
E:C)d V 1 hereby affirm that 1 am exempt from the Contractors License Law for the
W31n ti following branch.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
I_ O< which requires a permit to construct.alter,improve.demolish,or repair any support
lwY� to its issuance,alsort requires the applicant for such tic file a signed statement POWER DEVICES
prior 4 PP Penni B
W 5_<0 that he is licensed pumumt to the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
%XOL' 9(commencing with Section of Division 3 of the Business and Professions Code) VALUATION
or that he is exempthcmfmm and Ne basis for Ne allegedAn 1 i f
gYlPauma OUTLETS-SWITCHES-FIXTURES
FZC) Section than
five
anyapplicant for a permit subjects the applicanuoacivil Penalty of
pc�O not m1. oan rofthe roddollars Way.
"y,oTmyempl NEW RESIDENTIALELBCTR SQ,FT. STORIES TYPECONSTRUCTION
yFm ❑ I.asowncmfthcpropcny,ormycmployoeswiN wages asthcirsolecomlensminn,
W�,.. will do the work.and the structure is nm incendedoroffered fursale(Sec.7044,Business
and Pmfcaain I,Code Th.Conamelora License Law does not apply to an owner of
own propeumnypwInyces,.provided ihat suchheirmeopnmvanemdwenhtosdamocnssest uintended
ten
de d armfered Eustis.hIf.
OCC GROUP RLSUNITS
hrwevcthebuildingmimPnvetnIxsoldwihinonoyearoction, owner- TOTAL:
builder will have the burden ofProving that he did not build urimprovo for pumoxo
of
alcJ.
❑ 1,aa owner nnbe prnpeny,am exemxivety contracting elm Beenaed enmmmoev u, QTY, - PLUMBING PERMIT FEE FLOODZONE nPN
Linstruct the pfoject(Sce.7044.Rosiness and Professions Code:)The Contractor's
icense Law dresnot apply manowncrofproper who builds or improves throccum and PERMIT ISSUANCE
who contracts lorsuch projects with acontructor(s)licensed pursuant to the Contractors ALT'IiR-DRAIN& WATER FA
License Low. V - (' ) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this mason BACK FLOW LT.DEVICE OUTSIDE FEES
P TE
SANITARY Y N
Owner Date DRAINS- OO R.ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL FAN Y N
❑ (hereby affirm that l have acenificateofconsenttoodf-insion,oracenificare of FTX ES-PERTRAP RECEIPT#
Wmkers Compensation insurance or a cerificl copy Nermf(Sec.3800.Lab C.)which AS-FA.SYSTEM-1 INC.40I1TLE1'S PARK FEE Y N
vers all employee:underdn'permit. /.���^! RECEIPT#
Policy# BUILDING DIVISION FEES
Company aJ s < GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FFM
❑ Cmified ropy is hereby famished.
❑ Certified copy is filed wiN the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CHETTPICATE OPEXEMPI'ION FROM WORKERS' GRHASETRAP SOILS FEE
COMPENSATION INSURANCE.
(This section need not be completed ifthe permit is for one hundred dollars( I.
SEWER-SAN AR ST MP.A.2( ❑ ENERGY FEE
or less.
I crony that in the per4rtmmnce M the work for which this permit is is...it (shall WATER HEAT ENT � T
emplry any Kwon in any m as to become subject tic the orkcru PAID
Compensation Liwad Culifornin Date—so WAT EATING Dam Recdpt#
Q Z Applicant
Z 0 NO TICE TO APPLICANT:I L after making this Certificate of Exemption, houW N !SIDE AL B. SQ. TOTAL
F' LI) become subject to the Workers Compenmtiun provisions of the Labor Code,yo must -
� , forthwith comply with such provisions or this permit shall the deemed revoked. BUILDING FF:E
L.7 " SEISMIC FEE �U
a Q CONSTRUCTION LENDING AGENCY
I hereby affitrn that is a connection lending agency for the pri forromic n
u Z L: ELECTRIC FEE
U O Ne work for which this Pennit is issued(Sec.309].Civ,CJ TOTAL
Ledds Name
[E. F Leader's Address Q Y. MECUANICA ERMIT FEE PLUMBING FEF.
U I amity that I have mad this application and state that da.above information is MECHANICAL FEE
corer.Iagrce ereomply with all city and county ordinances and state laws rclaing to PERMIT ISSUANCE
F" a• buildingeommuction,and hereby awronce representatives ofiftme ins nion.prn the
V] CONSTRUCTION TAX
U z above-mentioned Pmpenyfar inspection and keep es. A RORA OMECH.
(We)agree dgm ra save,indemnify and keep hornless the City of Cupertino idCtagainst
Iiabilitics.judgmmU.cosu and expenses which may in any way accmcagainst said City AIR HANDLING UNIT(1'010,00(1 CFM)
in consequence of lh�{�mtinS his permit.
.(�1�ZrJZr r 2 -/ �* AIR HANDLING UNIT(OVER Ift"CFM)
Signature of AppliccaannUContmctur Da EXHAUST HOOD(W/DUCIO PAID
HAZARDOUS MATERIALS DISCLOSURE H IRA'I ING UNIT(To 100,000 BTU) Date Reecipt#
Will the applicant or future building occupant store or handle hurafdous material TOTAL:
asdelined by the Cost Municipal Code,Ch.ptef 9.12,and the I Loth and Sol,,, HEATING UNIT(OVER 100,000 B-I'U)
Cola,Scetion 25532(.)? V ENTILA'I']ON FAN(SINGLE RESIDI IF S
❑Yes. ❑ No
ISSUANCE DATE
Will the apPlicatnorfumrebuildingoccupant use equipmemordeviceawhich emit BOILER-COMP(3HP OR 100,1000 BITH
�harardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100.000 BTU) � ' D
Grand?
❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.FT. / I
1 have mad the humorous mmenals requirements under Chapter 6.95 of the UL l
California Health&Safety Code,Sections 2550x,25533 and 25534. 1 undersand that Cf/
if the building does not currently have a tenant,that it is my responsibility to notify the (Jf I
occupant of the ic,itements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or.affirm ed agent Date TOTAL: ISSUED BY:
OFFICE