28047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
DD:BING-MECHAICAT. PERMIT NO. 28047
CITU'QP CUPESION PING PROJECT
CT[DEN OFIC
NICAL
BUILDING DIVISION APPLI�.'ATIOLV�PF)RIU'IIT \I{WLDINI:PROJRC"f:IDEN'I'IIrIC_A'f1oN� -
BUILDINGGAADDRESS: SANITARY NO. APPLICATIONSUBMTITALDATE
164lq3 Q r UNIT# LOT "-RS
OWNERS NAM PHONE:If CONT} CI'OR'S NAMC: LIC NO: NIC CONTRO
.s
/!/crrl L ons 3 9 7 3100 GQ S
I ARCtvTECT/ENGINEBR: LIC NO: ADDRESS; El
GG��CEI'' o u- o2G36 rLfa �:g,&,� -r.w� - .�; ;,. , FEB .
L(/5 QTY. EM RI-' x a rFEE t O l tTt a�' '�B[1FLDING PERMIT INFO
C ./' /, ��- ^ �aD ;'9 'g RT k Y t } BLDG -ELECT PLUMB IMECH
1nJ1Jrr 146 Ca45(y < PERMIT ISSUANCE E 1:1 El
LICENSED CONI OR'SDECLARATION APPLIANCES-RESIDENTIAL - )OB E� SCRIPypN
GCZ Thereby effrmCENSEDiCONI uACTOR'S DECLARATION
(commencing with rug'�V,f/I�V-U�VSCRIP W
FOO Section 7000)of Division 3 of the Business and Prifessioas Code,and my license is in PANELS
mC fuilfomeandeffect.
<Z, License Class Lie.11UP T0200 AMPS
m?ti Dale Correct- 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
Z O'z ARCHITECTS DECLARATION OVER 1000 AMPS
O c-- I understand my plans shall Ix used m public records.
OZ—Q SIGNS ELECTRICAL
6 2 j Licensed Professional
��Q OWNER-BUILDF,R DECLARATION SPECIAL CIRCUITIMISC.
KOiU I hereby affirm that 1 am exempt from the Corommo is License Law for the
W 3 LL y following mason.(Section 703 1.5,Business and Professions Code:Any city or county 'TEMP.METER OR POLE INST.
1_"�4 O which requires a psis a,conswct Sher,impmv,,demolish,m repair any strumae
f,}� primmilsism...c,alsorequires theapplirun,for such permiuo file a signedaummem POWER DEVICES
,WCO thin he is licensed pursuant to the provisions of the Conuunor'a License law(Chapter SWIMMING POOL ELECTRIC
dr, 9(commencing with Section 7")o(Division 3 of the Business and Pmfentions Cade) VALUATION
,_y or that he isexempt themfmm and the basis for the alleged exemption.Any violation of OIITLEfS-SWITCHES-FIXTURES
FZQ Section7031.5byanyapplicamfornpermitsobjatsth,.,liea tioacivilpeneltyof
RSa not mom them five
rofthndreddo.oTmyempl NEWRRSIDENTIALELCCfR _SQ.FT. STORIES TYPECONSTRUCIION
KFp ❑ LssowneroDhepropeny.ormyemployas with wagesesthcinolecampensidum.
will domewark,and the structure isnot intended moffrmAl for sale(See.70ki.Business
and Professions Code:The Contractors License law docs not apply to an owner of
progeny whobulldsorimproveamereon,and whodunit such work hinewforthmughhie OCC.GROUP RES.UNITS
employees,provided Nm me arc such improvecnnot imendcd m offered for ads.If,
however,the building or improvement is sold within one year of completion,the owner-
buihder .will have the harden of that he did not build or improve f TOTAL:
proving prov purpomo
sale.).
❑ I,azownerofthe Progeny,amexdusrvely contruYmg wimli¢nsed conirect t QTY; 1a i� ,,PLUMBING PERb11T. - FEE FLOOD ZONE APN
consmact the Project(Sec.7014,Business and Profcasions Coda)The Convectors
Licanae Lawdoeunotappiyia anownerofproomy who buildsrnimpmvcstherion,end PERMIT ISSUANCE �.
whocoatracts for such projects with acontmetons)licensed pursuanuotheconvacers
License Law. ALTER-DRAIN&VENT-WATER(GA) ' FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE Ou I SIDE.FEES
SANITARY YN
Owner Daie RECEIPI'p
• URAINS-FLOOR.ROOF.ARI?A CON
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihembya nsatihmlhev morafiwe ofcopyt mof(S..3B o,L.h C.)ahiof FIXTURES-PER TRAP RECEIPT#
'Wmkers'Campensetion lnsunmaorucertifiedcupy thereof(Sec.3gal,LubCJ which PAR E Y N
covers all employee's under this permit. GAS-EA,SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM.OVER 4(EA) PNCHECKFE
❑ C n f W copy is hemby furnished.
❑ Certified copy is filed with the city inspection division. GRI?ASPANDUSTRI.WASTE INTERC R R GME
CERTIFICATE OF RXEMPTION FROM WORKERS' GREASETRAP O E
COMPENSATION INSURANCE
(This section needs becompletW ifthe permit is Enron,hundred dollars BUOO) SEWHR-SANITARY-STORM Js.200Ff. NERGY FEE
orle sJ
Icenify that in the performance of the work for which this permit is named,l shall WATER BEATER W/Vp 9LBCTR
not employ any person in My manner so as to bacmnm subject to the Workers' PAID
Compensation Lawsof California. Date WATER SYSTKMfIRBATING { Dam Remold It
O Z Applin nt _
0 NOTICETO APPLICANT:If,after making this Comficam of Exemption,you should NEW RF.SIDHNTI PLMB. SQ. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
� , fon ,sith comply with Such provisions.,this permit shall be decmcdrevaked, BUIL-IG FEE
rte] CONSTRUCTION LENDING AGENCY SEI IC FEE
1 hereby affirm that there is a construction lending agency for the performance Or
V O the work for which this Permit issued(Sec.3097,Cu.C) TOTAL: ECTRIC FEE
Lenders Name i p p p ' x {
I'L' F Lenders Address QTY,bipys"$ CY uMECHANICALPLRMITa C� a , `::F PLUMBING FEE
V 1
certify that I have reed this application and mea that the above information is k'klU
7" LkI correct l agree in comply with all city and county ordinances and sure laws relating to PERMIT ISSUANCE. MECHANICAL FEE r
buildiagcomwc,ion,andhembyauthedze meptesentatums ofthis city to enter upon the CONSTRUCTION TAX
Vabove-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemmi fy wd ku p harmless the City of C.Inamno.,am.,
liabilities.judgments,costa and expenses which may in any wayacemeagainst mid City AIR HANDLING UNIT CIO 10.000 CFM)
in cone seance of the mg
ni
of,his pert ,.
AIR HANDLING UNIT(OVER BLOOD CFM)
tore of Ap menVCammcmr J Data EXHAUST IIOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant Roe or handle haurdo.s material EIF-,TING UNIT(OVER 100,000 BTU) TAE:
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes El Na VENTILATION FAN(SINGLE RESID)
Will theapplicaorpa
fomm buildingnecunt moequipment ordevices whichemit
BOILER-COME SHE OR 100,IIW BTU) I¢5U - DATE
m
hazardous air conuminaam az defined by the Bay Ates Air Quality Management BOILER-COMP(OVEH 100,000 BTU) p
District? MAY 1995
❑Yes ❑No NEW RI5IDEM'IAL MHCII. SQ.FT.
1 have read the haurdous meanings mquimmenta under Chapter 6.95 of the \ CITY ser wren I u
Califomia Health&Safety Code.Sections 25505,25533 and 25534. I undersand at
if the building does not currently have a moral.that it is my responsibility to notify the
occupant of the requirements which mon b,met Our to issuance of a C,rificae of
Occupancy.
Owner.,euthonted agent - Date TOTAL: ISSUED BY:
OFFICE