28359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE'RTINO BUILDING-ELECTRI ALPERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL O' C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATItIS - o J
BUILDING ADDRESS //A UNIT# LOT# SANITARY NO. APP`^LIICAT^I/ON SUBMITTAL DATE
VERS NAME: � PONE: C RA PHONE E: L�d� l La�
t9 I.i���••// N/C CONTROL#
R IT A'1'/ENGINES LIC NO: ADDRESS: ❑
CONTACT: I +V1 PHONE' QTY, ELECTRIC PERMIT ' FEE ' BUILDING PERMIT INAO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE. ❑ IT-I/C'Ir.
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb [fivn lhminm liwnsed under p gwl I BOB DESCRIPTION
pay ya provisions of Chapter 9(commencin 1M1
r�1CC Section 9000)of Division 3 of the Businessand Professions Cods,and my license is in PANELS
fWw fol I far.and eRoc '-''`
¢y License Class�Lic.# Y^4+74* UP TO 200 AMPS
m bay
Date Commemr 201-1000 AMPS
z FO N'b ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.Pr.
O IZ^Q I understand my plans shall be used as public records.
h ; SIGNS ELECTRICAL
a� Licensed Professional
u1 OWNER- ILD DECLARATION SPECIAL CIRCUIT/MISC
°a4 I hereby is ked that 1 a1 exempt fro the Contractor Code:
Any city
for try
0.13 am fallowingdue.permit
LS, 1,amessm Profession,demolish,
e oli Co de:Anycity mcomny TEMP.MEI ER POLF.INST.
IaJ'O which requires a permit sones eh alter,imp ve,dem ail is or repair any oaddee"onson,r° prior to its isehmnce,u inquires the applicant fo och pennino fleasigned statement POWER DEVICES
W<a that he is license coammtheprovisionsofth Contractor's License Low(Chapter
pC� 9(commeno' hh Section V1100)Of Divisinn3of eBuslnessand Professions Code) SWIMMING POOL ELECTRIC VALUATION
y`❑y
or scxootpt therefrom anti the basis nr the el ged exemption.Any violation offITfLP.'f3-SWITCHES-NIXTURBS
,ZP Sec on 9031.5 byany opplicnni fo por,n uF s eap Ihmnnoueivilpenaltyrf
a t urethan five hundreily lar' �-
a O 1,aumwnfoettc ee NEW RESIDENTIALELECFR _SQ.FI'.
u� cap ❑ ape, Y oyeiswilh taiduc adecompensalimi, STORIES TYPE CONSTRUCTION
y3- will oemwork,andl - Untiondedor cin for sale(Soc.9044,Business
and nfessimis h ntmctora Licens awAo not apply to an owner of
grope ywhabuild veethereogand odoessuch orkhimselfnflraughhis
moreInyees,P'rovldo - "mchimp'rov entsarenolinlendedornfferedforsale.IL OCC.GROUP RES.UNITS
howdve the baildingor or,rarrear, Id within one yearofcompletion,Ne owner- TOTAL:
builder 'll have thebtr mprovi that he did not build or improve for purpose of
sale). ' I - - ., -
propery yeomraetng with licensee cen0ucmmm TY. ' PLUMBINGPERMIT' �F13E. . FLOOD ZONE
❑ I,ae wnerofthe t, exdusivel Q h APN.
construct t e project(Sac.9 ,Business and Professions Cotler)The Contractors
Liermael.a doesnotapply a erof gingery whobulldsorimprovesthereontrodI PERMIT ISSUANCE
whoumtrue forsuchpn etswhhaeomractor(s)licensedpunuamtothe Contractors
License Lax WATER(EA)ALTER ;FFEE SUMMARY
❑ 1 in ex rapt ua r Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE - OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,SO REA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Ifornbyaffrm Nntlhaveacerificme of wnsenuo selginsure,ora certifunreof SCHOOLTAX Y N
FIXTURES-PER T RECEIPT#
Workere'Componsationlnsuranoo eracerifed Dopy tihereof(Seu3g00,Lab CJ which PARK FEE Y
s covers all employee's under this permit. GAS-EA.SYSTEM-1 INC LETS RECEIPT#
Policy# BUILDING DIVISION FE ES
Company GAS-EA.SYSTEM-O ER4(
❑ Cenifiedcnpylsherebyfumished. r PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. ORFASEANDUSTRLW S ,1 FOR• GRADING EFF:
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section need not be completed free permit is forooe hundred dollars($10) 9ENFR-SANITARY-STORM0 ENERGY FEE
or less.)
I eerlfy that in theperformance of the work for which this pemth is issued,l shall WATER I(EATER W/VENT/ELEC'I'ft
not employ any person in any manner so as to hecome subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTENUTREATING
Q Applicant Date Receipt#
O
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
L•-' TA become subject to the Worker's Compmention provisions ofthe Labor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked BUILDING FEL' '
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
') Z I hereby affinm that here is a construction lending agency for the performance of
U O the work for which this permit is issued(Sed.3097,Civ.C.) TOTAL: FLECIRIC PER
Lenders Name
O VLenders Address QTY, s ' s MECHANICAL PERMIT "'EEE, PLUMBING FEE
LTa I certify that 1 have read this application and state that the above information is s"
marvel. logmemcomplywilhalleityundcoumy ordinances and state lows relating to PERMITISSUANCE MECHANICAL
building construction,and hereby authorize representatives ofthie city to enter upon the
U 7 above-mentioned property,for inspection puryoses. ALTER OR ADD TO MECH. CONSTRUCTION,TAX
rte- (We)agree to save,Indemnify and keep females,the City of Cupertino against
liabilities,judgments,eostsundexpensesoc
h may in any way accrue against said City AIR HANDLING UNI'f(TO 10,000 CPM)
fyuende of the a,of this 1,.
7-7.4fr AIR HANDLING UNIT(OVER IO,WOCFM)
iggoalues.f•71IIimm/Comradto Date EXHAUSTI IOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO 100,000 BTU) DDo. Receipt#
Will the applicant or futurebuildingB occupant store o,handle hazardous d Safety
as Code
dio the Cupertino Municipal Code,Chaptu 9.12,aad the Health and Sa@ry HEATING UNIT(OVER I00,OW BTU) T09'AL:
Cotle,Section 25532(a)?
❑Yes ❑Na VENTILATION PAN(SINGLE RESID)
WIII the applicant ant,S,building by the
A.,Air Quality Mwhichdmh
BOILER-COME(3HP OR 100,000 BTU) ISSUANCE DATE
hazardV air oenmminan11 us deFlneO by the Bay Aron Air Quality Management BOILER 100,1100 BIG)
nistrmt? P
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. All)
I have read the froSafety
Coed,de,
materiels 5505,2menta untie Chapter understand
0[the ���
CaliforniahebuilHealth&So[euy C a,Se eons art, hot
11 is and 25534. I under tend tthe 7
if Irebuildingdoes nm currentlyhaveatenant,thatitis myresponsibilityernotify the ZVI
occupant of the requirements whish must be ma prior ro issuance of a Certificate of
Occupancy. CiiY r
Owner nr umlhonzed agent Date '1' �- ISSUED BY:�
OFFICE