28240APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - EI.KCTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
IIUII.DING PROJN.CI' DJENI'IF'ICATION
PERMIT N
yC�J •LJ
L A a� w O
028240
BUILDING ADDRESS:
SANITARY NO.
AR'LICATIONSUBMITTALDATE
LOT #
B
'l1WfIliNB NAMd: — PIIONH:
A`RRCCHIITE/C,T/�JBINEER: LIC NO:
CON '1'RAL`IY)R'S NAME LIC NO:
ADDRESS
NIC
❑
CONTROL#
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �'�'
14• r El 0
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I em licensed under pravisionsol'Chaptnr9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section 7(IW)Of Division3nf the Business and Professions Ctiderindra,ficerackin
lull lifrcc and effect. 2 2
It License CI LIc,
PANELS
UP102WAMPS
s�('I
KI / lam
Dae Convenor ��.1
ARCIRIECPS DL'CLARATION
I understood my plans shall be used ss public records.
201 - IOW AMPS
OVER !"AMPS
SQ. F1'. FLOOR AREA
f/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER.RUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt from the Contractors License Law for the
9'13MP. METER OR POLE INST.
Following answer, (Seaion'/031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demnlinh, or repair any structure
prior to its Issuance, also requires the applicator for such permi no fi lost signed statement
POWER DEVICES
thul he is licensed pursuant to the provisions ofthe Contractors License law (Chapter
9(commencing with Section 700p) of Division 3 affix, Businessund Professions Code)
basisfortheapplicpft to civiny l andity of
or b7031.5 by fhercfmmnt for
Saban myapplicantdell forapermit subjects the applicant to civil penalty of
SWIMMING POOL ELECTRIC
J ///'''��� VpALUATION
/_ [,�/D•��
LO/
9,0
OUTLETS -SWITCHES- FIXTURES
than five
not more than Gve hundred Jollau (f3W).
❑ neroffheptapent'.orm
tin (See, compensation.
NEW RESIDENTIAL ELECfR S .FT.
STORIES
TYPE CONSTRUCTION
othev amdtheswnurcismorintendede offeredfor min (See 44, Boniness
will o,imenyeeswithwed far
to
and Professions Cumrecrora
ons Law aces not apply m an owner of
lCodedsm a1'he
enywh andwho arestach workhimselfnrthroughhis
nd who
oweem whnbuperivi improvesch improvements
employecx,provided thus tech impnrvemems are not intendedmoffered foraale. If.
OCC, GROUP
RES. UNI'T'S
IIA17 / Gv
7
however, the building or improvement is sold within one yearofcompletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT
sale.).
❑ 1,mownerofthepmpny.amesclusivelyconvactingwithlicensedcontmetorsto
ROOD ZONE
APN
conewef the pout (Sat. 7014, Business ora Professions Code:) The Contractors
License lawdae not apptytoanownerofpropenywhobuildsorimpmves thereon.and
PERMIT ISSUANCE
whocommcu fm sach projects with rimmo4etor(a) licensed pursuanJath, Convectors
License Law,
ALTER -DRAIN& VENT- WATER (EA)
IEC SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
PACK ROW PROTECT, DEVICE
OUT D. FEES
SANITARY Y N
Osom DateRECEIPT#
DRAINS - BOOR, BOOP, AREiA,COND.
WORKMAN COMPENSATION DECLARATION
I
SCHOOLTAX Y N
❑ Ihembyafdrm that l baveacertifica,rfemsenuo self-insure,maceniffcateof
Wnrkece'Compensafion insurance ora anified co thereof (See.3S00,WNCJ which
FIXTURES -PER TRAP
RECEIPT#
]FREE YN
m
corcu ellem to�y�e�a I nfnk _
P /V. ^-� 53
Policy #
GAS -FA. SYSTEM -1 INC,40UTLETS
\l RECEIPT#
BUILDING DIVISION FEES
1�p�
Company I -46,1 J
GAS -EA. SYSTEM -OVER 4(EA)
PLANCHECK RE -1
❑ Cerifictimpyisbembyfumished. I
Certified copy is file] with the city inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SHWER- SANITARY -31 ORM BA. 200FT.
ENERGY FEE
('Thissection need not becompleted iffhepernd is forore hundred dollars(f100)
u less.)
WATER HEATER W/VENT/ELECIR
Icertify that or The perfomernce of the work far which this perm, is issued, l shell
not employ any person in my, manner- u e Workers'
�(�7J
PAID
Compcnaaion Lewsof Califrrin. Dae
WATER SYSIFMRREATING
Data Receipts
Applicant
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
NOTICETO APPLICANT: If. after making this Cerificateof Exemption, you should'
became subject o the Worker's Compensation provisions of the Tabor Code, you must
forthwith comply with such provisions or this Permit shall be clamed revoked.
BUILDING FEE
^
D
SEISMIC FEE
a p
CONSTRUCTION LENDING AGENCY
I hereby mfrm that there iso umarucfion lendingagency for the performance of
the work for which this permit is issued(Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
W
U
LembTvName
Isndef, Address
QTY. MECHANICALPLRMIT FEE
PLUMBING FEE
I certify first I have real this application and state that the above information is
mrrect. l agree to comply with all city am county ordinances and share laws relating to
PERMIT ISSUANCE
MECHANICAL FTE
building concoction, and hereby amomor repmsenutives of this city turnover upon arc
above-mcmmicatpprop for inspectionpurposes.
ALTFRORADDTOMECIL
CONSTRUCTIONTA%
(We) agree to save, indemnify and keep harmlessthe City of Cupertino against
coarsing ex may in anywnyuccme against said City
AIR HANDLING UNIT (TO IB,000 GEM)
consequencethe thiseeandi.
in crnsequence of The graining of This permir.
AIR IIANGLING UNIT (OVER 10,000 CFM)
Signature of Applicam/Contmaor - Dan
EXHAUST HOOD(W/DUCT)
PAID'fY$�fZ ftp "Z.
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt If
Will the applicant or future building occupant store or handle hrrmdous mdmind
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
HEATING UNIT (OVER 100,1100 BTI!)
TOTAL:
VPNI'ELATION FAN (SINGLE RESID)
Cade, Section 25532(n)?
❑ Yes X.
NOILER-COMP(3HP OR IW,WO B'N)
ISSUANCE DATE
P A R
Will fheapplicamorfufurt huildinga:cupamouequipmemurdeviceswhich emit
BOILER - COMP(OVER IW,m) It ru)
hazardous air co lam as defined by The Bay Area Air Quality Management
Ilisvicf!
❑Yes ^aNEW
1 have read the haramous materials requirements under Chapter 6.95 of me
JUS 30 •y(](][JJJ
sero I
RESIDENTIAL MF.CIi. SQ. FT.
Culifomia Hwlfh & Snfefy CMl , Salinnx 25505, 25533 end 25534. I undnaand Thar
iffhe building does nat curently have a tenon fumy rtsponsibiliry to notify Ne
CI I Y Vr u kranI Hvv
acupoa oft(he re u menu which must prior to issu of a Certificate of
Occ
Fc p
ISSUEDB
Own em orizedegenf Dae
TOTAL:
OFFICE /
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ens{one 0 aim designation This This Is w original design and must Scale: 1/2'= 1' Date oe/ao/gs
g n ere eubleR to wdgcabon on not be rebased or wpled unleae
job sits and adjustment to Pt Job applicable fee has been paid or fob Designer
conditions. order placed. --
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Dmlgn : 05/Ze/g6 Deg no.
ens{one 0 aim designation This This Is w original design and must Scale: 1/2'= 1' Date oe/ao/gs
g n ere eubleR to wdgcabon on not be rebased or wpled unleae
job sits and adjustment to Pt Job applicable fee has been paid or fob Designer
conditions. order placed. --