28127 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
B IL IN-- TRICAL PERMIT NO. t
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 281,27 O 4 n 7
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 2 8 1,2 1
BUILDINGADDRESS: p SANITARY NO. APPLICATION SUBMITTfAAL DATE
/ 0,Y3 2 IDROOK wE-LL UNIT# LOT# L6��
OWNERS NAME: �� ,PHO":� ���` CONTRACTORIAZ 'S NAME: LIC NO�02 : N/C CONTROLk
ARCHITECT/ENGINEER: a LIC NO: 5 ESS: - ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ULE PLUMB MECH
PERMIT ISSUANCE F] ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPTION
PattezOO Thereby afOrmthat l 3 ofth Bminxamal reficsof Chapter9(commencin eism ��
POO Section]000)of Division 3 of the Business end Professions Code,and my license is in PANELS I Cb r.'N
giV U full force and effect.
Azad Licari lass Lic.N UP T0200 AMPS
tiCit. 7 Con7SD 201-1000 AMPS
20 as A CHITECTS DEC tic two10 SQ.FT.FLOOR AREA $ISQ.PT.
OVER 100(1 AMPS
1 onderenand my plans shall be used as public records.
�y SIGNS ELECTRICAL
Licensed Professional
kad' OWNER-exempt Rn the Cor TION SPECIAL CIRCUIT/MISC.
OaU 1 hereby affirm that I am exempt from the Casions o License Lew for the
W 3 0.ha following reams(Section]o3 L5,Business and Professions Cade:Any city or foamy TEMP.METER OR POLE INST.
W ON.] which require,n permit to cones the alter,improve,demolish,or repair any swment -
} e its pursue the ions of the Co Ds License
ted statement POWER DEVICES
prior yuires pp permit g
W O p 9 f he Is licensed with
Section
to the provisions of the me B.,irors License Lew(Chapter
9that heis
exempt t$refromandthe Division the theed exemption.
Professions Code) SWIMMING POOL ELECTRIC VALUATION
W..h or that h70315b therefrom ant f the Permit sujeasegedexemantto civiny l
of OUTLETS-SWITCHES-FIXTURES
9emian]031.5 by any applicant(orepermh subjects the appllcwnoodvil penolty of
I morethanfivehundreday.or ($500). NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
m n❑ oche wrk,and
the
offiand for guasalei(Sec. 044,Business
L will do thework,and the he Contractor's
License Law does not apply.to son Business
and propartyProwho
hiobuilds
u Code:improves
ve tthe....License Law does not apply la an owner of
mot wri Lyes,lrovi improvasthereogeermans due.suchwasudkbimselfonhrough his OCC GROUP RES.UNITS
awnempinyees,pingar improvement r ehimprovemcnrsafense ewof ompleeeed fienattheo n r-
f.
bowevepthe ave t ngaren ofprovig thasolt
he idnot build of completion.the owner-
builder will have the burden of proving that ha did not build or improve for puryose of
le')' QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Iuct the pr ject(Sec.70,nm ex in sis sand Professions,
C licensed Co amorsto
Licensed the project(Sea]044,Business and Professions Code)The Careon.a d PERMIT ISSUANCE
License Law does not apply ctanowner ofpropertywho builds rsimproves thereon.and
Lho icense comment for such Projects with oCnntraznor(s)licensed pursuanto nhe Contractor'sContractor'sLlceoso ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Scc. ,B ffi P C for Ihis'renson OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY .Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that i have acenifcaneofconsemtaself-insure,oracertiftcaeof FIXTURES-PER TRAP RECEIPT#
WmIner%Ccmparawfon insurance or a certified copy doneof(See.3800,Lab C.)which PARK FEE Y N
covens ell employee's under this permit GAS-G.SYSTEM-I INC.4 OUTLETS RECEIPT it
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified wpy is hereby fumishW.
❑ Certified copy is Bled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthepermit is for one hundred dollars($10D SEWER-SANITAR S EA,200FE ENERGY FEE
orles%.)
I certify that int he moraree of the work for which thispermit is lamed.I shall W RHEA CTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of Califerma. Dane WA REATIN Date Receipt#
O Z Applicant
0 NOTICE TO APPLICANT:If,after mem in this Certificate of Exemption, r TOTAL:
g pion,you should NEW ID TIAL PL SQ.FT.
Z L/1 become object 1.the Workers Compensation provisions of the Labor Cade,you..at
forthwith comply with such provisions or this Permit shall be deemed revoked. - BUILDING FEE
C[I (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC ME
V. p Lenders Name PLUMBING FEE
0 U Leader,Address - QTY. MECHANICAL PERMIT FEE
T certify that I have read this application and state than the above information is MECHANICAL.FEE
�" CTI correct. I agree m comply with all city and county ordinances and state laws relating no PERMIT ISSUANCE
huilding foranuction,and hereby authorize represemenives of this city to enter upon the CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wa)agree to save,indemnify and keep harmless the City of Cupertino against
liabilinies,judg nts,atnsand expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
in consoquenee f the Wring of this Farah.
AIR HANDLING UNIT(OVER Ig000CFM)
Signature ofA fu nmwftr i /1 tea EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ITO 100,000 BTU) Date Receipt#
Will the the Caantorfuture Municial Code,Chnt apter
9,m handle Health a,mamtlal HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapmr 9.12,and the lieehh and Safety
Code,Section 25532(a)] VENTILATION FAN(SINGLE RESID) Lit*4-WaN
❑Yes ❑No
BOILER-COMP(3HP OR 100,0010 BTU) ISSUANCE DATE
Will theapplicantorfumrebuildingoccupum useequipmentordevice,whichemil P
hazardous it curtailmen s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) D
Disvicn9
❑Yes EI No NEW RESIDENTIAL MECH. SQ.PI'. /
I have mad the hazardous materials requirements under Chapter 6.95 of the �gg�
Cvlifomia Health&Safety Coda Semions 25505,25533 and 25534. I understand that 'I
ifthe building does not currently have a tenant,that it is my responsibility to notify the Uf•("Up
occuparequirement,nt of the reirement,which must be men prior 0 issuance of a Certificate of . H
Ofeap:mfy.
Owner or authorised agent Oats TOTAL: ISSUED BY:
OFFICE