28023APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO UU11,11INU - EI"
APPLICATION/PERMIT PLUMBING - MECHANICACIL.
BUILDING UI VISION BUILDING PROJEADENTIFICA'1']ON
PIiRMITNO.
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BUILDINGADDRESS:
SANITARY NO.
{a�.N'
' iOC /a ? �rC� / /"� UNIT# LOT 3
JAPPLICATIONSUBMITTALDATE
.
OWN RS NAM!: pI10NE:
a
QfOR'S NAME LIC NO:
2
N/C
El`76A
/ CONTROL#
ANCHITECT/ENGINEER: LIC NO:
D 5:
CONTACT: PHONE.:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INTO
M,IFJ}�/
B ELECTf-'� )
�s p 'r
YAn Q2 40 99 —_hS2
PERMIT ISSUANCE
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P100
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LICENSED CONTRACTOR'S DECLARATION
wilb
Thereby of
scsicessprovisioni... Coal., and
3 of the
Section ](N10)of DivisionJof the Business and Profession Code, and myliccmeis in
full force and efreci.
pppL1ANCES-RESIDENTIAL
JOB DESCRIPTION
PANELS
GF.GW
m=y
ZOO=Z
m
License Clan Lie.p
Date Convector.
UP T02W AMPS
W`
201 -IOW AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used n public records.
OVER IgO0AMP5
SQ. FT. FLOOR AREA
I ��41.0
I` 4�D
f/SQ. FT.
SIGNS ELECTRICAL
Licensed Professimnnl�
OWNER-BUILDER fir nt the CRATION
I hereby uflimt that I an exempt from the Contractors License law for the
following reason, (Section 7031.5, Business and Profession Code: Any city or county
which requires a permit to construct cher. improve, demolish, or repair any structure
prior to is issuance, also requires lheapplicant fmmch Pentam file atigrmdswmment
that he is licensed pursuant to the Provisions of Ne Com ucmls License law (Chapter
9(commencing with Section7")of Division 3 of the Business and Professions Cade)
Srthat 703tSbyaexempt h ,herfrom anCt. basis for the ged exemption. Any ivitpemioy of
actsalle
]031.5 iv any applicant for a pemtit mhjecm the applicant m. civil penalty of
nm morethan fivehundred dollars yemp.
❑ I,asownarund,property,ormycmperadolwithwageorand.rmle comperomas.
willdaslass as The tmeishot '. License apply(Sit7044. Business
and Professions Calc: The Comamm'e License Law etas mol apply m an owner of
Law
9
iciciayyy O aFU-
F��co
on
K Op
aaxo2
W_rn
QSection
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a _
L
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SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
1 1
f� ff�NV L✓
OUTLETS.SWITCHES.FIXTURES
NEW RESIDENTIAL ELECTR SQ. FT.
STORMS
TYPE CONSTRUCTION
,.,rlywh.buildimimprites thermn,md whodoesmch work hineselfonhmugh his
ownemployess,provided that such improvements arenm intemdedorofferedforvle. If,
OCC.GROUP
RES. UNITS
however, the building or improvement is sold within oneyear of completion, the owner-
hadder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PI7RMIT FEE
vie.).
❑ I.mownerafthepropemy.amexclnlvelycmumtingwithlicensedcmm comto
FLOODZONE
qPN
construct the project (Sec. 70414, Business and Professions Col The Contractor's
License Law das not apply m un o wnem f properry who builds or improves thermn. uW
PERMIT ISSUANCE
whocomacts fmmch projects withacomamnds) licensed mounted to Comrsemr'apLTP.R-DRAIN&Vt
Licene Law.
-WATER BA
( )
FEE SUMMARY
•
❑ 1 am exempt under Sec. , B & P C for this rcoaon
BACK ILO GTECT. DI: CB
OU I SIDE FEES
Owner Data
D S-PI,OOR. ROOF, ARBA, D.
SANITARY
SANITARY Y N
WORKMAN COMPENSATION DECLARATION
Ihemby affirm that] have a cmificam of mnvm mvlLinsum, orattrdficme of
Workers'Compensminn lnsurenceoracenified copy thereof (Sec. JNW,Leb CJ veli'
SCHOOL TAX RFCEIPI'N N_
PARK FEE Y N
FIXTURES - PER TRAP
GAS -EA, SYS INC.4 OU' 5
c❑
overs all employee's under this permit.
Pat,#
R EIPTN
UI DIN IVISION FEES
Company
GAS -I—S STE JFR4(13A)PLANCHIWK
L2C,�t
V
❑ Certified copy is hereby famished.
❑ Certified copy is fled whir the city inspection division.
GREASFUIW WAS CEPTOR
GRAD
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
RF.ASF
SOI
SE ANIT R -VO HA. 2W .
ENERGY FF.F. N 00
(Thissatim rad.mbecompleml Bills prior, is forone hundreddollaa(51 I
or less.)
WIT RATER Will 'I'/ELECTR
I cenify that in the performance of the work for which this Permit isiZ.ad,Ishn
Z
not employ my person in my mother so n m became subject to the Workers
C..'runtionlawsof Cslifomia. Date
Applicant
WATERS STEM/IREATING
PAID
Date iprp
z 2 NOTICE TO APPLICANT: If, after making this Certifiaximid Esemplim, you should
H4 become subject to the Workers Compensation provisions of Ne labor Code. you most
W�fnnhwilh comply with such provision orchis penni[shall beJamed revoked.
NEW RESIDENTIAL fil SQ, FT.
OTAL:
FE
BUILDING E i—
per, Gz CONSTRUCTION LENDING AGENCY
-^� I hffi
Thereby arm Nat there is a construction lending agency for the perfon - --f
SEISMIC FEEe�
AW T
ELFCTRI
L) Q the work for which this permit is issued (Sec. 3007, Civ. CJ
Lattice. Name
U.
F Landers Address
QTY, MECIiANICALPFEE
PLUINERMIT
U I certify that I have read this application and sumo that the above infornmama Is
correct. l agree to comply with all city and county ordinances and state laws raising to
building construction, and hereby authorize representatives of this city [center upnnthe
V Z above-mentioned property for inspection purposes.
MECH A ,P.
CONSTRUCTION TAX
PERMIT ISSUANCE
ALTER OR ADD TO SUCH,
(We) agree to save, indemnify and keep hmmleas the Cay ser Cupertino against
liabilities,judgmenm,cru andexpenw whichmay inany way me gains vi City
AIR HANDLING UNIT (TO Iq(gOCPM)
ash
co.ugnnce of the grand., of this permit.
AIR HANDLING UNIT (OVER IO." CFM)
EXHAUST I IOOD(W/DUCT)
PAID
Signuwre pplicom/Cnmamor D e
HEATING UNIT (TO IWAX) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Racal #
Will the applicant or future building occupant store or handle limitations material
as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Heahh and Safety
HEAPING UNIT (OVER IW,g100TU)
TOTAL:
Coda Sutton 23532(e)7
11 Yea ❑ No
VENTILATION FAN (SINGLE RESID)
building
Will ,air
equipmentserality
BOILER- COMP IMP OR Ifgl,1100 BTU)
I 4Cj ATE
^9 !
as
hazardous air conmminana as defined by the Bay Area Air Quality Management
contaminants by Bay Mawhonagement
District?
/IIy
BOILER -COMP OVER 100,OM BTU
BOILER )
❑Yea ❑ No
have mad the huzmdous materials requirements under Chapter 6.95 of the
NEW RISIpENT1AL MSCI I. SQ. Ff.
California liealth & Safety Cade, Sections 25505,25533 and 25534. 1 understand thate building docs not curcn0y have n mmml, Ihot it Ia my rcsixcsihility m nofl y iliaupant
[1 of the requirements which must be met prior to issuance ofa Certificate of
upancy.
issuED BY:
ner or amhement a gent Date
l
0FFICE