28404 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOLDING-ELEC I'RICA L PERMIT NO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IIJHN'rIF1CA'OON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'I1
l0 05 � acl --Wwv oz., LOIN 1�IS
F. H M F CONT CTOR:SNA LIC NO:
N/C CONTROLp
RCHITECOENGINEER: LICNO: ADDRESS: ❑
72 1
CDN TACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERM( INFO
@LUG. .LIiCf PLUMB rp1ECF{�.,
iL PF,Rb11T ISSUANCE �� �L�Q( 1��I/[�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RVSIDHNI'IAL JOB DESCRIPTION
poo (hereby affirmmaIs.ofth Business
ProfesioCh.prt,and mmecenseai whM1
FOO Section7")
and of Division 3of the business and Professions Code,and my license is in PANELS
a full farce lass-feet.
FQZ� License Class Lic.N UP T'02fX1AMPS
,",<h
Date Contractor 201-1000 AMPS
Z FOorZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA E/SQ.FT.
1 understand my plans shall be used as public records. OVER 1000 AMPS
�yF� SIGNS ELECTRICAL
Q Y Licensed Professional
zz�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUITMISC.
X0 y O 1 hereby affirm that 1 are exempt from the Contractor's'License law for the
'31-vFi following reason.(Section]031.5,Business and Pmfessions Code:Any city or county TEMP.ssWWR OR POLE INSI'.
F a O Q which requires a permit to construct,alter,improve,demolish,or repair any structure
'.}7to its issuance.also the applicant for such Permit file a signed statement POWER DEVICES
prior quires pp c permi g
K O hm he is licensed pursuanno the provisions of h Commemrs License Law(Chapmr
aXo4 9(commencingwith Section]000)of Division3o eBusinessand Professions GNc) SWIMMING POOL 17LEMIC VALUATION
4]—m or hm be is exempt therefrom and the basis for ed eae a yviolation of I
F.ZQ Smrio 7031.56y any applicant for
tori cap tic t anvil penalty of OUTLETS-EWITCHFS FIXTURES
5 E ore man five handred dollars(E L s L `J•�V
CF� .uownen heprope.Y. ye to u as
mei olecompensation, NF.WREMDENTIALELECR SQ.FT. STORIES TYPE:CONSTRUCHON
y3'c willdo work, (hes c of dh o' ff�d sale(Sec.]04J,Business
and Professions le TI C vac tar's Li AY•(/A' s not apply to an owner of
prnpeny wb vee dwh u<h work himxlGtrmroughhi.<
own employ tr dlhmsuc p vin tareamtinrendedorofferedit'sala If, DEC.GROUP RES.UNI IS
howeveghebuildin o improveme t Id within one year ofcompletion.the owner- T L:
builder,will have the u n of pmvin that he did not build or improve for purpose of
sale.). e QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las owner oeca(Se property,am Business
and ontmning imux Clic:)The marmm's
onswet the project(Sec.o ano ncrof,s and Poifywhosionx Cr imp The thereon,
whovo Lawdoesnorapply manowavermaopcny whobuildsmimpmves hereon,and PERMIT ISSUANCE.
whocommcu forsuchpmjectswihaconhaaor(s)li<e sed punuantmme Conuacmrs LTER-DRAIN&VENT-WATER(Epo �' FEE SUMMARY
License law.
❑ IamexereptunderSa. B&P C for this memo BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y
Owner m RECIiIPr p
DRAINS-FLOOR.ROOF.AREA,COND.
WORKMAN COh ATION DECLAR TION SCHOOLTAX Y N
❑ IherebyaI1!1`bm.b cenificareofconzenuo self nsure.or a certificate of MIXTURES-PER TRAP HECEIITp
CAAPPLIC��T
Cmmpensati urance ora renified copy herbaQ ec.3800.Lab C.)which PARK FEE Y N
coversle x under this permit. s GAS-EA.SYSTUM-I INC.4 OUTLETS RECEIPT
BUILDING DIVISK, FEES
GAS-CA,SYSTEM-OVER O(FA) I'LANCIIIiCK FEF.
ifed ropy is hereby,fumishe
ifed copy is Rled:vith thecit in ton division. G0.EAS171NUUSTRI.WASTT:INIERCEPfOR GRADING FEE
RTIFICA F 1PI'ION FROM W E GREASE THAI' SOILS TEL
SATION INSGRAN
is ecf n completedifthe permit Tone hand deflate lEl(p) SEWER-SANITARY-STORM BA.200I7. ENERGY FEL
nify the int eperforman<c of me woe or which this permit is issued,l shall WATER HEATHS W/OENDELEC1'R
loy any any an c m became subject a.the Workers' PAID
0 z ;tion laws of California. Ua¢ WATER SYSTHMORHATING Recer,#
Z TO APPLICANT.IL aft making this Cenificale of Exemption,you should NEW RESIDHNI'IAI.PIN B. SQ.FL TOTAL:
^ ubject,.the Workers ompessalma provisions oflhe Labor Code,you must
> comply with.such una or his permit shall be demed revoked. BUIL INi E
ONSTRUCTION LENDING AGENCY SEISMIC FI..n Nanhere is a covuurtlon lending agency for the performance of T' F,LEC1"RIC PE[
U 0 the work foe which this pem n is issued(Sec 3097,Civ.C.)
Lenders Name
D" F Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEI
U 1 certify that 1 have read this application and stare that he above information ix MECHANICAL BE
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE /
F' (Inbuilding construction,and hereby amhonze reposereetivuofhis city,.comer upomthe CONSTRUCT( NTAX
U Z above-mentioned property for inspection purposes. ALIIiR OR ADD TO MECI I.
(We)agree m save,indemnify—it keep harmless the City of Cupertino against
liabilities.judgmen¢,costs andoxpcnuswhich mayinanyway e< eu st so' ify AIR HANDLING UNII'(TO 10.000CFM)
equenee Hing oRhi t AIR HANDLING UNI'T(OVER 10.00ICIT1)
Signature of Appli roI. fate L'XHAUSTHOOD(W(DUCT) PAID
HAZARDOUS MATERIALS ' LOSURE HEATING UNIT(TO I00,9IXIBTU) Dwe e
Will the applicant or future building occupant whundle hozaedous material
eco defined by the Cupvniau Municipal Code,Chapter 9.12,and the Health and Safety IEATING UNI"T(OVER 100,000 B U) 'IT)'I'Al.:
Code,Section 25532(a)R VEN'1'[LAI']ON FAN(SINGLE RIiSID)
❑Yes ❑No
ISSUArJ4:el TE
Will the applicamorfuture Inildingescupanr uacequipment ordeviceswM1iebcmdn BOILER-COME(3HP OR WyG)B'I U) •YO^-� Y
hazardous lir cxmmrtlinanta as defined by the Bay Are.Air Quality Mmtugcm011 BTU)
ent BOILER,COMP(OVER 100.0 ,
District' Cp ` .l
❑Yeh 11 No NIiWRESIDENTIALMECIL SQ.P1'.
1 have read the Intonations materials requitemema under Canner 695.1 he N LVrr J
C.lifomia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that N
if the l udding does not currently have a tenant,that it is my responsibility,.notify the
wupam of be requirements which mmr be mm prior,.ism...v of a Camftea,.of
Deeapaney.
Ow'ncr or authorized agent Date L: ISSUED 13Y V`y
OFFICE