26098 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO. O
CITY OF CUPERTINO APPLICATION/PERMIT PI.UMHJNC-MECHANICAL
BUILDING DIVISION BUILI3ING PRO JECI'IDEM'IFICATION
BUILDING ADDRESS: ( �/ (/h O SANITARY NO. MMICYUONSUBMITTALDATE
,3O 1--�' 00/x•• VrrzVe— UNIT LOT# 1
MS NAME: Y PIL N` CONTRALT9R'S�ME: LjCf`0 NiC CONTROL#
V. Lne _ (av
CHITCCT/EN'GINEI. : LIC NO: ADyRE 6cq
CONTACT: PHONE: QTY. '-'\ELECTRIC PERMIT J FEE BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
PERMIT ISSUANCE ❑ ❑ ITL ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DMCRIJ91OON
yy I hereby affirm Nm l am licensed underprovisionsof Cbaptese)(commencing with A
00 Taction T000)nf Division of the Businca.end Professions Code,wJ my license is in PANELS
U full force anJ effect.
6Z License Class Lic.# IIP T0200 AMPS
v~i,6J v0.i Date Connote 201-EXX AMPS SQ.FT.FLOOR AREA SISQ.FT.
ZOZ=Z ARCHITECTS DECLARATION OVER 1000 AMPS
1 understand my plans shall be used as public rxorda.
r= SIGNS ELECfRICAI. I A (/� Ilm h ® II
Licensed Professional L C` --` lI L N
�� OWNER-BUILDER DECLARATION SPECIAL CIRCUFUMISC. f—� 1
O U 1 hereby affirm then 1 em exempt from the Contra .,',License Law for the \(I ✓ t
3: r¢n following reuon.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE.INST. LVA D
t(L Oco J which mquima a pernil to conswm,alter,improve,demolish,or repair any swcmm
}�
prior to its issuance,echo rcyuirc.+the applicant each permit rile asignedxwmmem POWER DEVICES XV
K Q p that he is licensed pursuant to the provisions of the Contractors License law(Chapter TE
qp� SWIMMING POOL ELECTRIC VAL ATO -�
n o 9(commencing with Seencn 700(10f Division 3hfthe Business and Professions Code)
oc or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURES
t y QSection 7031.5 by any applicant far a permit.objects the.pPlicanuo a civil penaity of
not more than five hundred dollars(5500).
ES❑ NEWRFSIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
� p� ❑ I,asownerofchepmp rty.ormyemployee.withwagesastheirsolecompcmation,
dwilldo the work,andthe structure isnot intendedoreffered foraale(Sec.7Qlq Business
.. and Professions Cade:The Connectors License Law does nor apply C,An owner of
propertywhobuildsorimproves thereon,and whhdoes such workhimselforthroughhis OCC.GROUP RES.UNITS
n employ..,prov idled that such improventems arc not intended ur offered for sale.If,
M1owercr,the buildingorimprovem<m is sold within one Year ofcomPleuon,the owner TOTAL:
builder wil I have the burden of proving that he did not build or improve far purpose of
sale.). QTY, PLUMBING PERMIT FEE FLOOD ONE APN
❑ Lmownmofthe property,amexdusively<ontrxtingwith licensed conv.ctorsth
nnswet the project(Sec.9049,Business and Professions Coded The Commerors PERMIT ISSUANCE.
License taw does not apply to vn owner of property w ho m i Ids m improves thereon,and
who Comm%fm Inch projects with acontrnctosR)licensed punuanloft Communes ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
FEES
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSID
SANITARYYN__
Owner Dote DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'#
J WORKMAN COMPENSATION DECLARATION SCHOOLTAX RYECFIPTN N
Ihcreby.(Tote thatlhaveattnificme of consent to self-insure,orattnificate of FIXTURES.PER TRAP
orkms Campensmionlnsmanceoracenifiedcopy thereof(Sm.38M.Lob CJwhich PARK FGF. Y
RECE119'N
covers ell employee's under this permit. GAS-CA.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FEES
Policy N
Co. any GAS-EA.SYSTEM-OVER 4(13A) PLANCIIF:CK FEE
allied copy is hereby famished.
Certified copy is filed with the city inspection division. GRGSFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
f@issectionnmd bribe completed ifthe permit is foronehural dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELECIR
nm employ any person to any manner so ss to become subject to the Workerrs PAID �—
ComperaationLawsofCalifomia. Date WATER SYSTEMITREATING Date Receipt#
70zH O NOTICE TO APPLICANT:if,after making this Cafifi.m.fExempti......should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
t,t become subject the Worker's Compensation previsions of the Labor Code.you most BUILDING FEE
forthwith comply with such provisions or this Permit shot]be rimmed revoked.
LkI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affum that there is a construction lending agency for the performance of ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Nvmc PLUMBING FEE
U" P Lender's Address QTY, MECHANICAL PERMIT FEE
O IU2-I I cenify that 1 have mad this application and state thin the above information is MECHANICAL FEE
reel.]agree to comply with all city had county miinances and stem law.eluting th PERMIT ISSUANCE.
building construction,and hereby authhnmexpresemadvn of this city theater upon the CONSTRUCTION TAX
(J z above-mentioned property,for inspection Purposes. ALTER OR ADD TO MECH.
(We)once to save,indemnify and keep humnless the City of Cupertino against AIR HANDLING UNIT(TO 10,000 CFM)
liabilities,judgmrnu,chs¢andexpenseswhichcony in any way accrue against Intel
ace of the gran' (thio permit.
,xs AIR HANDLING UNIT(OVER L0,000 CFM) �s
Sgn,.
im.f ApplicanVContraam r� Date I EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO I DT000 BTU) One Rceeipt
Will the applicant or future building occupant store or handle hamrdous material HEATING UNIT(OVER 10.0(111 BTU) TOTAL:
as defined by the C.Fenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seems,25532(.)^ VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
Willm..,liummPomn Wildmiloccupanmxequipmeatordevicm whichemit BOILER-COMP(NIP OR 101h000 BTU)
air Condominiums as der m by the Bay Arm Air Quality Management BOILER 100,000 BTU)
isWCRs p)
11 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A 0 8/
I have read the hazardous nationals requirements under Chapter 6.95 of the OAR
California Health&Safety Code,Sections 25505,25533 and 25534. I wdenmM that Y Ilgrt a
if the building does not currently have a tenant,that it is my responsibility,to notify the _19rou occupant of the requirements which must he met poor to issuance of a Certificate of �S
Occupancy. V �,
Owner or amhurimd agentDe1e TOTAL: ISSl1ED BY:
OFFICE