28343 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL UL G-MECH N ICA PERMII'NO,
APPLICATION/PERMIT PING PRO.ECTID MECHANICAL
BUILDING DIVISION IIUII,BIrvC 1'KO.IFC'1'IUEN'1'IPICAT']ON 28343
BUILDING ADDRESS: SANITARY NO. APPLICAI'IONSUBMITTALDATE
79027 80LkPAP QR ,
UNI'I'N LOT#
OWNERS NAME: PHONE CONTRA/CTOR'S NAME:4L�a,RLJOyG as-r-0-.) ?4 Fuca-SLIC NO:
w NIC CONTROLls
ARCHUTCI'/ENGINEF.R: LIC NO: A S:
i 22 Sallsc7d6�
CONTACT: PHONIi:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ZO&71 Ro&rS 37&7-G7o� ELECT PLUMB MECH
PERMIT ISSUANCE s
LICENSED CONTRACTOR'S DECLARATION APPLIANCP.S-RESIDINTIAL 1 )prre�orren0q �
pay I herebyaffnm that l am licensed underpmvisionsofChapter9(commencingwith ,^` V��Jl'�s,�s'�p �
00❑ Section 7")of Division 3 of Ne Business and Professions Code,andmylicerwis in PANELS as F `�rV
PUU full force and effect. (r) 6'13 UP TO 200 AMPS
Fy W License Clas_ Lic,p
y y Doc Contoa 201-hall AMPS
.ZUN ARCHITECT'S DECLARATI011 OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plots shall be used as public records.
Ln W SIGNS ELECTRICAL
¢ �j License)Professional �I/j�
P.1W ¢ OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. WAR �C
px.O L F 1 hereby affirm tba 1 am caempt from the Contractor's License Law for the 5 1996
u13 Coao following mason.(Section 7031.3,Business and Professions Cale:Any city or county TEMP.METES OR POLE INST.
�J which requites a permit to construct,after.improve,demolish,or repair any shucnre Ur
M�7 prior to its issuance,also requires the applicant forsuch Permit file a signed statement POWER DEVICES 1.V1�Ln1 BVU
he he is licensed pursa im to Ne provisions of he Contracuxe,License Law(Chapter
m'ke�y 9(amtmencing with Section IBM)of Division Sof the Bminexsand Professions'Code) SWIMMING POOL ELECTRIC VALUATION
W_,,, Smith 7031.5 by uherefmmanf the for a Permit
subjetshedexemant10 civilPnaa anlty of OUTLETS-SWITCHES-FIXTURES
tZY Section 70him iv eundredicnmrs($5Brmit subjecta the epplicammacivil penally of f�
STD t mom shoo five hunAred dollen(5500). NEW RESIDpl,ELECRt SQ.FT. STORIES 'TYPE CONSTRUCOON
6❑p� ❑ I,asownerofthepropeny,ormyemployeeswithwagesestheirselecompensation.
p^, will Jothcwork,multhestrucmmixnm intendedoroffeod forsalt(SecJ(VW,Business
.. and Professions Cale:The Contractor's License Law does not apply to an owner of
propenywhobudsor
iliman
provexthemon, d whodoesauch workhiaselfonhroughhis WC.GROUP RES.UNITS
ownemployees,provided Nat such improv sold
wit art one
intendedmofRred forxal n If.
however,the building burden
of proving
is sold within one year or improve
omm a for t purpose
r-
bale.). will have the harden of proving that he did not build or improve for purpose of
alt.).
❑ I,mowneraf Nepropeny,ameaduxivelyconwming with licensed conwnunm QTY. PLUMBING PERMIT' FEF FLOODZONE pPN
construct Ne project(Sec.]014,Business and Professions Cale)The Comnetor's PERMIT ISSUANCE.
License Lawdoesom apply toanawneruf mcp eny who buildamimproves thereon,and
whocommets forsuch projects with awnhaator(s)licensed pursuunumhe Comractor's ALTER-DRAIN&VENT-WA
License Law. FEE SUMMARY
❑ Ian exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE SANITARY OUTSIDE E FEES N
Own<r Data DRAINS-MOOR,ROOF,AREA,CONE). RECEIPT
WORKMAN COMPENSATION DF.CLARAI'I NN SCHOOLTAX Y N
❑ Thereby affirm thetiheve ecenificnte ofcnnscm to sdf-insure,ore cenipcate of FIXTURES-PER TRAP RECEIPT#
Wwkers'ComFp9eYnsatinn ldnssurance nrnemified copy Hereof(Su.Jtl00,l�b CJ which PARK PER Y N
covers all—/ els tyt25,Ipix grID{L Of ION
S Y l , 6 Y GAS-EA.SYSTEM-1 INC.4 OUTLETS
BUILDING DI BION FEES
any �q a ra"oN^ GAS-EA.SYSTEM-OVER 4 TA) PLMs CIIECK FEE
❑m Certified copy is hit famished.
❑ Cenified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thiesection neednabecompletediftheperran fabacnehundreddollars($100) SEWER-SANITARY-STORM EA.20OIT. ENERGY FEE
or less.) IV
I certify that in the pertornmee of Ne work for which this Permit is issued,Ishift WATER HEATER W/VRNT/ELECIR
not employ any person in any manner so or to became subject to the Workers' PAID
CompanAotai Lawsof Califomiu. Dan WATER SYSTEM/TREAT'INC. m Receipt#
C) NOTICEITO APPIJCANT:If,after making this Certificate of Exemption,
you,yumuld NEW RESIDENTIAL PLMB, SQ,FT. TOTAL:
z beconve hwithc reply the such
Comprnsathis Prmitshe]be,the
emed voked.umust ^
fmnM1wiN comply with mch provisions or pertniuhall be deemed mvotrd. BUILDING FEE L
I
W O ffimCONSTRUCTION LENDING AGENCY SEISMI 1+
^a I hereby at that them is aconstruction lending agency for performance of ELECfRI IN-
for,work for which this p.it is issued(Sec.3097,Civ.C.)
U. P Lende/s Name PLUMBING FEE
LendersAthat
QTY. MECHANICAL PERMIT FEE y
V 1 certifyfy that I have read this application and sore that the aboveinformation is w
Y'
A. correct.Ingrce mcomply wiN ell city and coumy ordinances and tote laws rtlming to PERMIT ISSUANCE MECHANICALF E
F" buildingcmmsuuction,and hereby nuNwim mpre4enutivea ofthis city menter upon the CONSTRUCTED TAX
V Z above mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree intrinsic,indemnify send keep harmless Ne City of Cupertino against
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.00II CFM)
in c ofihe graning of this permit.
AIR HANDLING UNIT(OVER IO,g10 CFM)
igma fApplicant/Contractor /sem Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNITUO I00,000 BTU) Date ReNipu#
Will Neapplican or future building acceprmt aturt or handle hazardous material HEATING UNIT(OVER 100.000 BTU) I TAL:
as define)by the Cupertino Municipal Code,Chapter 9.12,and the Henith and Safe,,
Calc,Section 25532(a)7
ElYee 11 No VINTILATION FAN(SINGLE RESID)
❑
WilHhea licant urfuturcboidin BOILER-COMP(3HPOR 100,000BTIE ISSUANCE DATE
pp gocmpunt useequipmemnrdeviaswhich emit
hazardous atr commitments as defined by the Buy Area Air Quality Management BOILER-COMP(OVER IW,"BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
/ I have read the hmmdous mmeries requirements under Chaptw 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25574. 1 understand that [sem
if the building does not curemly have a tenant,that it is my responsibility to ami fy the
mupnnt of the regniremems which must he su
met prior to leunc,of a Cenifiano of ��-yy//
Occupancy. ���
Owner or auNorized agent Data T ISSUEDBY ��1��1..--//////--yyyy������////��))))))
OFFICE