28233 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO hit ILVING-ELKCI RICA I. PERMIT NO.
PLUMBING C MECHANICAL 28233
BUILDING DIVISION APPLICATION/PERMIT BUILDING
ING PROJOJ ECT IUEN'FIFICATIfIM1'
SANITARY NO. APILICA'I'IONAUB�Mra/I'IFIACDA'1'li
1ll1ll LO'ra
OWN $fl'�MIi /s�N PI Q COMI'RACfOR'S NAMIi: LIC NO: N/C CONTROL#
RCHIlEC4FisIGINEliR:1` LICNO: ADDRESS: ❑
CON'1'ACf: PHONE: BUILDING PERMIT'INFO
Q'I'Y. ELIiCIRIC PERMIT FEE
BLDG ELX I'I UMIi EC
PERMIT ISSUANCE Cy�SF/
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPUON
OCZ I hereby affirm that l am lieeneed under provisionsofCTzpmr9(commencing with
W00 Section]0M)of Division 3 ofthe Business and Professions Cede.and my license is in PANELS
UPTO2W AMPS
fullfo effect.
p<,ZW UA
LimClass ine Class Lica
may Untc Cmntrncwr 201-IINIU AMPS SQ.Fl.FLOOR AREA S/SQ.En
Z�yz ARCHITECTS DECLARATION OVER IMI)AMPS
O z_ I undcmanJ mY plane shall he usW as public mcords.
F=F-ta SIGNS ELECTRICAL
<YE_J Licensed Professional
KOM< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aU I hereby affirm that 1 am exempt from he Contractor's License Law Trump
FLLOmtelki ingrer,a .(Se[mion 7031.5.Bmmeavand Professions Code:Any ci y t t r.
-611 or coin y TEMP.METER OR POLE INS'
which requires a permit in nmswm,ether,improve,aomaL.n,or repair any swnarc
prior m its issuumce.itko requiresthealicunt ppformch pe.it o filen signed statement POWER DEVICES
Thar be is licensed pursuano Ne provision,of rhe Crawacmr's Urcow,Law(Chapter
W Xo� 9 th Section]000)of Division 3nf the Business aJ Professions Code) SWIMMING POOL ELECTRIC VALUATION
(commencing wi
or Than he is exempt herefrom and the basis for the alleged exemption.Any violation of
Fza Section 7031.5 by aPermit y applicant a peit subjects the applicam OUTLETS-SWI'TCIIIS-
nt a civil penalty of FIXTURES
num more than rive hundred dollars($500). NEW RESIDENTIAL ELECFRC S .FF.� E] Lasowncrnfthe Property,ormYemployces with wagexas theirsolecompensation. Q STORIES TYPE CONS'IRUCI'ION
ywill do The work,and the structure is not intended or offered fmsolc(See 7044,Business
and Professions Came: "e Ciml acmr's Utero Law docs not apply to an owner of
property whobuildsor improvesthereon,and whodoes such work himselfordwough his OCC.GROUP RES.UNITS
ownerriplayess.provided that such improvcmc th%arenot intenJW moffered Tarsale.If,
however,the buildingor improvement is sold within oneyearofcomplemion,theownic, T
builder will have the burden approving that he did nom build or improve for purpose of
sale.). FT.DOD ZONE
❑ [,as ownaof the finalist am exclusively tomcatting with licecontcontractorsQTY. PLUMBING PERMIT FEE
cJ contractors to APN
Lnstruct the t(Sec.Allo,Business and Profcssiom Cude:)'The Contractor's
icense Law docs not apply In anownerofprnlnrty whobstuds nr impnrse,lhercon,and PERMIT ISSUANCE
who contracts for such projects with acnmrunor(s)licensed pursuum to the Contractors
License,law. gLTER-DRAIN&VENT-WATHRIG) FEE SUMMARY
❑ 1 an exempt under Sec. ,B&P C for This reason BACK ROW PROTECT.DEVICE. OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,CONE. RF.CLIPTa
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm trial l have acenificam ofconsent mself-inmre,ora certificate of FIXTURES-PERI'RAP RECEIITp
PARK ILEI? V N
Workeri Compensation Insurance or re,oilicdoopylhereof(Sea.3gIN1,Lnb CJwhicn
coven all employee's under this permit. Gp5-PA.SYSTEM-1 INC.4 DUTLE'1'S RECEIPT a
policy If BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4IRA) PLANCHECK FEE
❑ Cmtlfied copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FTE
C[R'TIPICATE OFIi%EMlrl'ION IROMi}OORKERSCRFASE'112AP�'µ�5'��W SOILS FEE
COMPENSATION INSURA`5�f, r.
(This section need not beamplacJ ifthc permit ifi�lmwe undyed dollars(SIM) SEWER-SANI'T'ARY-STORM .2W ENERGY PEIi
or less.) �Fc+� n C w1
I certify that in the Tvalmrt ofthe work for wI&h this perm Iss dlltg�ll W ITTLE B 11.
not employ my person in any mama so as to become subject the WWWW% orx. PAID
Compensation LawedCalifomia. Dam G Dae Reccilh
DZ Applicant
O NOTICF.TO APPLICANT:If.after making this Cchificnm of Exemption,you should NE IDt TIAL PLMB. SQ.FT. OTAL:
hecomesubjecnothe Worker's Compenm0onprovisiogof the Luton GrQG,you owst
� � fonhwilh comply with such inovi.tons or This permits IMJeemcJ rcv IC BUILDING FEE
0. Q CONSTRUCTION LENDING A�NCY SEISMIC I'
7 z Iherehy affirm thanhem isaconsmructiun lending agetm}+$Uhp{Sf{ppn�nfp..flj-'+ .,,_„�a..�..a..-.� ELECOMIC
C) O the work for whichthis Ext is issued(See J09].Civ.C.)
Lvadeh Name if�
C`- I<nd F" Address QTY. MECI IANICAL PERMIT FEE PLUMB F:E
Iverti
V certify Than 1 have licit this city
an county
tyJ smote that the above iw"elatinn is MECHANICAL I'Ai
>^ W correct.Iagree anetuard hereby autyair eomay nNlnamauns statcity In Turner upon'he PERMIT ISSUANCI3
F' Z builvingconaructinnand herinspectionerpses. Ives ofthiscitytoenlar upon eche CONSTRUCFINTAX
V Z uMrv(We)Toned To vs. nd inspection purpura. ALTER OR ADD TO MECH.
(We)agree nt rove,indemnify ens sic harmless the City of Cupertino against
incoitiequencmf egranti of Tho which ma in any waynccme against said Ciry AIR HANDLING UNIT(TO IO,o00 CPM)
inconsequenceof egrati of Ni. limit.
/ AIR HANDLING UNIT(OVER Iq(XIB CPM)
Sip.3TaaasepA,, ConhxcAor Dale EXHAUST IIOOD(W/DUCT)
PAID
HAZARDOUS MATF,RIAI S DISCL RE HEATING UNIT(TO LM,000 BTLD Date R 7.
Will the applicant or future building occupant store or handle hazardous materiel HEATING UNIT(OVER IM,0MBTU) T TAE:
as defined by the Cupertino Municipal Code,Chapter 9.12.and be Health and Safety
Code,Section 25532nd? VENTILATION FAN(SINGLE RISID) -
❑Yee ❑No
BOILER-COME(311POR 100.000NIU) IIISjUbNCE DA' '
Will tair c..icnnimmin, re defined hy,the B.,AnnequipmentQuality heran
�`I
avanlmu.a air nmuuminams ns Defined by,the Buy Arca Air Quality Menagemenl BOILER-COMP(OVER 100,1300 BTU) fI.
isNen {w 90
❑Yea ❑No NEW RESIDENTIAL MECH.-SQ.Fri. ty N9 111Oa.
1 have mad the M1arardous materials rcquiremenks under Chapter 6.95 of the I JJa�
California Health A,Safety Code,Sections 25505,25533 and 25534. 1 understand that Uh(1(/pEk��N
if the building docs non currently have a tenant,that it is my responsibility to notify the 0
occupant of the mqulremenms which must M mat prior to issuance of a Ccnireate of
Occupancy.
Owner or suborned agent Date TOTAL: ISSUED BY: J-✓=+=J
OFFICE '