28003 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOINf�T" TFZTH PF.RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28003 O 0 0 J
Q
BUILDING PROJECT IDEN'TIF'ICATION Lo
BUILDING,�ArDyD�RIiS�S: /� SANITARY NO. APPWCATION//SSUBBMIITI'ALDATE
I`�—l�V UNITN LOIN
OW E SNA CONTRACTOR' NAM / LIC NO: N/C CONTROLN
CIETECDENGINEER: LIC NO: ADb SS .•JJ
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
,V_ ELECT PLUMB MECH
PERMIT ISSUANCE \Iry�f
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �JS�O,B DESCRIPTION
p0Z Ih7")ofDivihml 3 oft he B underrd Prioix...v ial-adcommencing with �� I✓,✓
n ottz Section hereby affirm than 3 dice Business end Psionssion nates dmy license wain PANELS
ybE fall force
and eff / 3,Zf
QQZW License�s Lic.N rat UP TO 200 AMPS
y Q y Data y/ Connector I r« 201-1000 AMPS
FyK ARCHITECTS DECLARATION OVER ION,AMPS SQ.IT.FLUOR AREA $/SQ.PT.
ZO ZO u 1 understood my plans shall be used as public records.
F Yl
SIGNS ELECTRICAL
2 Licensed Profestaione
ft a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MTSC.
a 00.F I hereby affirm therm I m exempt from to Canummr's License Uaw for the
'3 pro following reason.(Section 7031,5.
Business and Professions Code:Any city or county METER OR POLE INST.
HIm which requires a permit to co er,improve,demolish,or repah any e
Y� prunoitsissuana,ulmiequ" t iriplic red statement POWER 4VICES
WOO Nat he is licensed(meant to provisions of the Contractors License Law(Chapter
a a�' 9(commencing with Sectio 700))of Division 3 ofthe Business and Professions Code) SWIMMIN POOL ELECTRIC VALUATION
y y,n or tb:n he is exempt theref and the basis for alleged exemption.Any violation of OUTLETS SWITCHES-FIXTURES
Z< Section](131.5 by any up want for a pemtit subjects the applicant he a civil penalty of
resmoreffitionfivelimed dollara($500). NEW REST ENI'1AL ELECfIt —SQ.FT.
❑ I,mowneroftepr ,ormyemploy«ewitwegesuteinolecompewtion, STORIES TYPECONSTRUCTION
4322 willdothework,enddes trvcwrcisnotimendMorofPoretl forsale(Bm.]IM4,Business
and Professions Cottle: a Contractor's License Law does not apply to an owner of
propenywhobuildsorproves thetwn,and whodoes such w:d im anhroughhis
employees,provi dtetsuchimprovmentsammotinte ded oro awed Trade,IL OCC.GROUP RES.UNITS
ho wever,malmildin improvement issold witinoney 'on,theowner- .TOTAL:
harder will have th urdena(provingt thedidnotbuil o i for purpose
sale.). � TY PLUMBING PERMIT FEE FLOOD ZONE APN
❑ uct,a for I propeny4, eadu i c it He c motor
construct rhe pro' t(Sm.]044, r y < ons r scatheuntra0tor's
Licenulawd« mapmiects with
nywhoreon d PERMIT SUANCE
whence Losts fa such projmms with econv or(s)limn pursumnmhe Ca rors ALTER (EA) s
License Lnw. (' P8L SUMMARY
❑ 1 um exam t under Sec. ,B&P or this masonE
BACK FLOW PROTECT.DEVICE SANITARY Y N
Ow a, te RECEIPT(
DRAINS-FLOOR,ROOF,AREA,GOND.
ORKMAN COMPLNeard e, D ARATION SCHOOI.TAX Y N
❑ Ihembyaffin mhatlhaveucenifmuteofc neo eeIGinsureoracenificate of RECEIPT(
Wmtrri Com
at,
sumn<eorn FIXTUft[3-PER TRAP
(cess copy thereof(So,.3800,lain C.)which PARK FEE Y N
covers all employee's under mspctmn' GAS-EA.SYSTEM-I INC.4 OUTLETS', RECEIPTN
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ceniftedcapyisherebyfumished.
❑ Codified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF?
COMPENSATION INSURANCE
(This section need tali completed ifthe permit is parents hundred dollars($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
enify that in the perfinmmce ofthe work for which this permit is issued,l shall WATER HEATER W/VENTIELECTR
n ploy any person in any mummer so u to become subject r do Workers' PAID
ompensmion Isws of Califomie. Data WATER SYSTEM/IREATING Date Rmeipt N
Q z Applicant
NOTICE TO APPLICANT:If.eflat making This Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
_ become subjmt to rhe Wokere Compensation provisions afro Isbw Cade,you must
> foMwit comply wit such provisions or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm Ban them I..rammuctum lending agency for the performance of
Uto work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
L$. r_ Lenders Name
U
PLUMBING FEE
U Lenddr Address QTY. MECHANICAL PERMIT FEE
I certify Net I have mad this application and state That to above inf rmtmion is MECHANICAL FEE
Treem. l agree r M comply wit all city ecounty oninences and arta laws relating to PERMIT ISSUANCE
_ buildingeonsvuction,and hereby arhodxe representatives oftis city incineration ha CONSTRUCTION TAX
U Z above-menioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree r save,indemnify and keep harmlus to City of Cupertino against
rahilities.judgmems,enstsan xpens hich may in any wayamme again said ity AIR HANDLING UNIT(010,000 CFM)
in consequence of the gman of is Trim. ( ! AIR HANDLING UNIT(OVER 10,000 CFM)
Signor l'ApplicmVC scar Dme EXHAUSTHOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Recequ0
Vi ll the applicmt or form building occupant store or handle harardom materiel HEATING UNIT(OVER 100,000 BTIl)
as defined byte Caperton,Municipal Cade,Chapter 9.12.and to HoM and Safety
91
Code,Secmi25533(0)1
0 Yes ❑No
VENTILATION FAN(SINGLE REBID)
ISSUANCE DATE
Will the acontainant as building by the useequipmenmuality Management BOILER-COMP(3HPOR IfN),000 BTU) ^ A I f)
hemNow air contaminants m defined by to Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 1'�
4d District?
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. c
I have mad the hamrdous materials requirements under Chapter 6.95 of the ��� 1995
California Health&Safety Code.Sections 25505,25533 and 25534.1 undmrnd that C'T'
if the building does not currently have a imam,that it is my responsibility to notify to f/ I1nfrGcuT
AM
necuWnl of the requirements which must be met pd.,to issuance of o CeniOcate of F`urLNT�
Omtqu mey.
Owneror mtoriud agent Data TOTAL: ISSUED BY:
OFFICE