27948 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO 11ILMI G-ELKCTRI AI. PERMIT NO.
APPLICATION/PERMIT PLOAHIING-MECHANICAL n /I e
BUILDING DIVISION BUILDING PROJECT BEEN'I'IFICATION L LI o
BUILDING ADDRESS: / SANI'T'ARY NO. APPLIGTIONSUIEOUTAL DATE
J C (qqG
UNIT M LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NA LIC NO:
N/C CONTROL.#
U e
.'RCiLTF.CT iNGINEE : LICNO: AU RP : ❑
7-j e .9S"
CONTACT`: PHONE: ➢U
Q'PY, ELECTRIC'PERMI9' ILDING PERMIT INFO
' FEP. -
BLDG HLHCI' PLUME MRCH
PERMIT ISSUANCE ❑ 11 ❑ I&
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pKz Ihereby off.That lam licen.mA unJerprovisinnsnfChepwr9(c°mmtreingwith JOB DESCRIPTION
Ia900 Seelira9001Bmf Division 3ofthe Business and Pmfmsaimnx Crda,md on,license is in PANELS T/'(1/�� 1 �l_ D
f1a-CZW full force and arc t '• eQ,- / 64/
Q�L,Iy Dole Clas-� Lic.#_.1l�SG G UP T0200 AMPS V
m6y Dae Commcmr G 201-Iqp AMPS
F,o ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OZOZ=G I understand my plans shall he used as public records. OVER 1000 AMPS
P,ylFp W SIGNS ELECTRICAL
gi,{ Licensed Profcaximnal
ffLLLLLL1I OWNER-13111LDER DECLARATION SPECIAL CIRCUIT/MISC.
°�OOU I hereby ..(Se that 1 am exempt from the Cc.mrs Co License Law for the
W 3 n.'I¢ following mos°a(Section 7031.5.Business and Professions Code:Any city or mumy TEMP.METER OR POLE INST.
F 0 J which requires a pentJt to treses,nhtt,improve,demolish.or repair any swqurc
WY7 prior to its issuance,also requires the applicant for such Proms file a signed statement POWER DEVICES
me�p0 that he is fiecnscdpmrs.wn 1. he provismasof the Contractor's License Law(Chapter
a e� 9(commeneing with Section 9110marDlvisloo 3or Oto Bminussand Profcesions Cade) SWIMMING POOL.ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F;ZY
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of OEM TLETS-SWI'I'CI I ES-FIXTUR IS
SS 4
or mom than eve hundred dollars(550OL
KCS l.mownerofthe NF.WRESIDENTLALELECTR _SQ. STORIES TYPECONSTRUCDON
❑ property.ormyemploy<eswithwageasthcirsol,compemedmn,
a3— will do the work,and thestructure is not intendedoraffcrcd for sale(Sec.Tow,Business
and Professions Chile:The Contractors License Low does not apply to an owner of
pwitcOywbnbnllds nr improves thetenn,amd whadoes such wolchiamelfurthrougb his
own employees,providedthat such improvements we nm intended reoffered fursme.If, OCC.GROUP RHS.HM IS
however,the buildingorimpforment is sold within one yearofcompletion,thetwner- T AL:
builder will have the burden of proving that he did not build m improve for purpose of
salad.
❑ I,as owncruOM1e property,emeatlusivelycommcting wiNliunsedcnnwaors to QTY E
PLUMBING PERMIT 1' FLOODZONE AI'N
instruct the project(Sec.TM4,Business add Professions Code:)The Contractors SUANCIi
License Law does not apply man nwnerofpropany,who b^ildswimproves thenen,rand
who coronets forsuch projects with a contractual licensed prisua^tto the Gnmadnrs ALTIiR-DRAIN&VIiNT-WATER(13A) ' FEE SUMMARY
License Lew.
❑ 1 am exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y I ES N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,ARG,COND.
WORKMAN COMPIiNte ofoo DECLARATION SCHOOL TAX Y N
❑ Hisrebeas'Coyaferm thatlhave
rancem certificate opymcomf(ment to ee.38or aathC.) hickte of NECIiIPI'#
FIXTURES-PER TRAP
Workers'Compenemion Insurance oraoenlfrd copy 0ereof(Sec.3gW.l.ah CJ which PARK PI?N YN
rovers ail cmpin eI under this P mlil. GAS-EA.SYSTEM-1 INCA OUTLIi'1'S RECHIPT#
IWhy# -- if�.)�9 x1420 "Gt') BUILDING DIVISION NESS
C°r^Pa^Y�r//f6/ GAS-G.SYSTENFOVER 4(EA) PGNCHECK FEE
❑ Certified copy is hereby fumiAod.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRI.WAS'MINTERCI; TOR GRADING FEE
CPRTIPICATE 01:EXEMPTION FROM WORKERS' GREASE TRAP SOILS THE
COMPENSATION INSURANCE
(This union need nut be completed Hour permit is former hundred dollars(5100) SEWER-SANITARY-STORM FA.20OFT. ENERGY -ME
orless.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HGTER WNENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califumia. Date WATER SYSTEM/fRLATING Date Receipt#
Q z AFFlarm,
O NOTICE TO APPLICANT:IL utter ranking this Certificates of Exem t TOTAL:
p ion ,you must NEW RP.SIDF.NTIALI'LMB. SQ.FT.
r bees,ithcome mply the Workers isionsrti°n emit shallns beeemed Coda youmust
a � frnhwitM1 comply with such provisions or this permit shallbedmmed revoked. BUILDING F£F.
L2a CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of
U C) rho work for whleM1 this permit Ix Issued(Sec.3099,Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name - �; PLUMBING E
Q F Lmdees Address
MECHANICAL PERMITPLL FE
U I cenify that I have read this application and shire that the above information is
correct. l agree to comply with all city and county ordinance and state laws relating to PERMIT ISSUANCEMECHANICAL FEE
In building construction,and hereby authorize representat(vesofthisciry to enter upon the JO CONS'I0.UCf10N TAX
U above-mentioned property for inspection purposes. ACI'ER OR ADD TO MECH.
(We)agree to save,Indenai l'y and keep h.,Ic,.Wo City of Cupertino ngalnst
liabilities,judgments,costs and expenses which may in any way stere,against said City AIR HANDLING TIN Jr(TO 10,000 CFM)
in qi ence of the granting of this permit.
G���Jr�Q`I /?( AIR HANDLING UNIT(OVER 10,0111 CFM)
Signature rf AppllcadUCont c" FP'/Y Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00 BTU) a
Recmpt#
Will the applicant or future building occupant store or handle haverdous material IL
HEATING UNIT(OVER 1 W,WO BTU) TOTAh:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)?
Cl Yes El No VENTILATION FAN(SINGLE RESIDE
Will the opplicam or fuwre building occupant use equipment ordevitts which emit
BOILER-COME(31111 OR KILOS)[JIM)
ISSUANCE DATE
rhamrdam,air contnmmanrs its,alined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 WE U)
:iatriuT 9
❑Yes ID so NEW RESIUENTIAI.MECH.—SQ.PT. a,
I have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Heahh&Safety Coda Sections 8505.25533 and 25534. 1 understand that J
ifthe building does immanently have a tenant,that it is my responsibility to notify the
mecupam nl'Lha rmynimmems whi<b must be met prior In Issmnrz of a CcniOcam of
Occupancy.
Ownerm iewhodacdivem, Dae TOTAL: ISSUED BY:
OFFICE