28349 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELMA RICA L PERMITNO,
APPLICATION/PERMIT FLUMRING-MECHANICAL n Q /I (]
BUILDING DIVISION BUILDINGI-ROJECI'IDENT'IF'ICA'T'ION Lo 4J
BUILDIN//GA1DD11RFSryS: 1 / SANITARY NO. APPLICA'T ION SUBMITTAL DATE
,( y V a 11��2IV�' �"t.l UNIT# LOTH
WNPRS NAME: PHONE: CO RACTOR'S NAME: LIC NO: N/C CONfROLp
rwiso ss7-65r 14 ono (l- �v os
%RCHITECT/ENGINEER: IAC NO: ADDRESSu
L0S Ov IDIT� . ❑
CON'T'ACT: PHONN QTY. ELECTRIC P17RMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
lh,rebyaffirmthntlambcensedunderproakimaod Chuplar9(commencing with
1400 Section700sdnf Division 3 of the Basinessund Professions Code,,ted my license is in PANELS
yyM� qU full force and effect.
Fply License Class Lia'p UPT02MAMPS
m av4i
Date u
Cmatrmr 201-1000 AMPS
'0O ARCHITECTS DECLARAT'[ON OVER High AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O Z—D 1 understand my Flans shall be mud as public records.
M"ty SIGNS ELECTRICAL
6 5d'ay License)Pmfcxsinnul
OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
Q06 F I hereby, from that I am exnnpl from the Cmmnmmr's License Law ror the
Y1�Orn following reason.Section 7031.5,Business and Professions Code:Any city or county TEMP.MEIER OR POLE INST.
,ng which requires,permit to canssrvcl,ober,improve.demolish.or repair misstmcmre
K2¢7
prion,its issuance,also requires the applicant forsuch Permit.file a signed statement POWER DEVICES
fig' 0
that he is licensed promotionnntrac
o the Provisions of the Contractors License Law
Lgcz
LL 9(eimmencing with Section 7")of Division 3 of the Businesanid Prmfesslos,Cale) SWIMMING POOL ELECTRICVALUATION
X{y,�rA or that he is exempt therefrom and the basis forlheallegeJ exemption.Any violmimaof �! 00O. VU
Section]03L5 byanymppliconl>
lfmairmit subjectalheapoiammmuciAl penuhyof OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($50T.a NEW RESIDENTIAL ELECTR —SQ.❑ I,asow.errfthepropeny,ormyemployeeswithwagesaslhcinolecompensation, Q STORIES TYPE CONSTRUCTION
a3 v0 will dothework,undthestmcture isnot intendedoroffemal forsale(Seu.]044,Business
and Profeomic Cale:The Conbadors License law does not apply m an owner of
pmpeny who builds or improves Nclmn,and who does such work himself or through his
employers,providelmia such improvements arc nal intendedoroffered forsale.ll; OCC.GROUP RES,UNITS
however,the boldingor impmvemcnl is sold within one yearo!completiono
,thewneT.own TO'fAl:
builder will have the burden mf proving that he did am build or improve foo purpose of
'ie.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,asoe proDt(Sam. ny.am and ontmdings Cadccnudconteactonm
icswd the project(Sec.]Irmo Business end Professions Cade:)The Comrumra PERMITISSUANCE
License trawdmesflot apply ms with a c of pinpcny whosed purstoot rovesthereon,and 2.(,Q
who
irist"mdsfmsuchpmjecmwim ucnmmmmr(s)licenurl Punuenuuthe Convumrs ALTER-DRAIN&VENT-WATER(EA)
License Law. hEP.SUMMARY
❑ I um exand ander Seo. 1 II&P C for Ibis rntann ITt I (SIDE FEFS
BACK ,OW PROTECT.DEVICE SANITARY YN
Owner - Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,CONO.
WORKMAN COMPENSAHONDECTARATION SCHOOL TAX Y N_
❑ cra*Co affirm thatInsurance
certificate ofconunlmrof(Seaum,or Led,C.)which
RECF.IPI'M
FIXTURES-PER TRAP
Workcrr Compensation lrasumncemeceniEed ropy thereof(Su.3gW,Lah CJ which PARK FEE YN
overs all employee's under Ibis permit GAS-EA.SYSTEM-1 INC.4 OUTLETS •RECEIPT#
Palley# BUILDING DIVISION FEES
Company' _ GAS.11A.SYSTEM-OVHR4(EA) PLANCHECK FEE
❑ Cenificd copy is hereby fumish dJ
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRLWAS'IEINGERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectioflnced no,be completed ifthe permilis forma,hard.]dollars I$IW) SEWER-SANITARY-STORM PA.20pFT. EERGY FEE
or less.
I cenitylhnl in the performance ofthe .,k for which this permit is issued,Ixhall WATER HHAII ER W/VEN'I'/ELECTR
not employ any person in any manner so as to become subject in the Workers PAID
Compeasationiawsof California. Date WATER SYSTL'M/IRFATING Dem ReceiplN
Oz Applicant
z 2 NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should NEW R ESI DPNTIAL PLMD. SQ.FT. TOTAL:
!-+ !/J become subject m the Workers Compmordirn provisions of the L.1m,Code,you mass
mnhwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEF.
Qi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z I hereby affirm that then is a construaiin lending agency for the performance of
UO the work for which This .it isissued(Sea.309],Civ.C.) TOTAL:107W ELECTRIC FEF.
lenders Name
0 U lenderPLUMBING FEF.
Lender's Address QTY. MECHANICAL PERMIT FEE U
U 1 unify that 1 have read this application and anile that the above information is
r1' 0. coned.Iagree tocomply with all city tend county oNinances and sane lawsrelatingto PERMITISSUANCE MIiCIIANICAI.FEE
V) building construction,and hereby automise representatives ofthis city lomier upon the I
CONSTRUCTION TAX
U 7-r above-mentioned properly for Inspection purposes. Ala'ER OR ADD TO MECIL
(We)agate m rave,indemnify and keep harmle.the City of Cupertino again
Iiebilitia,judgmenm,costa arW capenuswM1ichlwyinany way ucrveugaimal acid Ciry AIR HANDLING UNIT ITO I0,00s)CFM)
in consequence of the granting or this penis.
AIR HANDLING UNIT(OVER 10.010 CFM) �./ pr
Migrationof ApplleunUCommrmr Dote EXHAUST]IO0D(W/DUCI. PAID�-zs-4S' �JL0 2
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 HTIH Date Receipt# -
Willlheapplictororfuture building nccupam store or handle hmmdous material HEATING UNIT(OVER 100.00s)RTU) TOTAL-
Code,
defined by the Cupertino Municipal Code,Chapin 9.12,and the Health and Safety
Code,Sectimt 25532O?
❑Yes 11 No _ yliNTIIAI]ON PAN(SINGLE RPSID)
8OILH8-COMP(3HP OR I W,S)O BTU) S�ANCE,DATE
Will the nppllcunmrfumbulldingocmm tpaus,oquipmnt
anrJovices which nail , I L�
hawre rdma air cnmaminants as defined by the Bay Area Air Quality Management
District. BOILER-COMP(OVER I/0.000 BTU)CI Yes Yes ❑No NEW RESIDENTIAL MECH.—SQ.IR #`$. AUG ^5 1"/y�"5
1 have read the harardoms mmerimis oldremems under Chapter 6.95 of the _
Culifomia Health&Sourly Code,Sections 25505,25533 and 25534. 1 understand that coUr I.UYtH �t T
If the building doer flat comendy have a mount.that it is my msponsmm llity notify the C
occupant of the requirements which must be,met poor to issuance of a Cenificale of
Occupancy. �J ,
Owner m indhnriseJ agent Dam TOTAL: ISSUED,,.
OFFICE