28079APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINOR
BUILDING DIVISION APPLICATION/PERMIT
ILIIINQ- LF. RICAL
PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
�i oO 0
L 79
tlU1LDING ADDNESS: /'J-�
/,/ I IS v 6 A2 UNIT.
LOT#
SANITARY NO.
APPLICA9'IONSUBMITIALDATE
Ow/p�Ey NA)p��/� /-� C/ /�f -NSE: COI/�T,�p)CfQR'g NRRij� G� iJ.IOC NQOS
I % i/K�/ {J 7Orl -�GeJ 3Z� W! L- (,ill G- 2 T// a
N2
COMM%RO/Lfp
GCONTACT:
ARCHI'1 C'UEJ /NEER' LIff: l
g
LBUILDINGG
PHONE:
ELECTRIC PERMIT
FEEMIT
PEERRMIT INFO
ISSUANCELICENSEDCONTRACfOR'SDECI.AhapeT9
I hereby ufRrLICENSEDCONT under ACTORvisDECL IOVTIr9 (commencingwirh
7201
L1ANCE5-RESIOENTIAI.TOB
DESCRIPTION
e'Section7")of
Division Sof the Business and Professions Code, and my license is inELSfull
force and effect.
Licenu Class Lic.0
02MAMPS
ate Cornracmr
1000 AMPS
ARCHI'rECPS DECLARATION
1 understand my plans shall be used as public recurds.
R 1000 AMPS -
SIGNS ELECTRICAL
SQ. FT. FLOOR AREA
S)SQ, ET.
Licensed Prrfewirnel
OWI DECLARATION
SPECIAL CIRCUIT/MISC.
form
1 hereby affirm that I em caempt from Ute Contractors
am exempt Low for she
following (Section 703 1.5, sinew and Professions ee Anse
m or rounry
TEMP. METER OR POLE W ST.
which s, a
which h, or re air
construct, improve,demolish, or repair mystructure
its requiresthevisiosofor ch
its issanpermit requirsthe applicant urease
POWER DEVICES
that the Commmi[ro
that he is licensed pursuant to the provisions of the Commnors and Pro Law (Chapter
pursuant La (Chapter
Section] OWI Division 3ofthe Pronasions Craft)
9(commencingthath
SWIMMING POOL ELECTRIC
VALUATION
isxemith
ed exemptio
orthatheis1.5 by themfmmnt and he Permit sthec.hedesemption. Anyviolationpsavaon of
he
by u a permit subjects the aPPlicanur a civil penal[Y of
OIITLEI'S-SWITCHES-FIXTURES
�_
net mom than hundred
net more tmnerothedo ny,or(yemp. withwagawthei(Sec. com7044.
❑ Lwowrk,
NEW RESIDENTIALELECIR_SQ. PT.
STORIES
TYPE CONSTRUCTION
and tpmpcny,armyempendee
will dothe work, and the Business
Business
and Professions Code: The Gmuamor's License Lure fires not apply to an owner of I'
he Contractor's
property whohuildsorimproves themnn, andwhodoessuch workhimulforthroughhis
ownemployeas, provided that such improvememsarcnot intandW reoffered basNe. If.
OCC. GROUP
RES. UNITS
however. the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY.
❑ I,as oe
adusis=it mfessiosCaJe:)
PLUMBING PERMIT
FEE
FLOODZONE
API4
Thesed
Contractor's cunswn the project (Tec. ]044. Business and Professions Cadeq'fhc Con[acmrs
pmjcct ce.744.
License Lew Joestach plytoanawncrofpropeny whobuildsoriml
PERMIT ISSUANCE
9. be Cercnn,end
Lic.Law. forsuchprojecu withecnntrecmds)licrnud pursuonumhe Conhanor's
Liccve law.
ALTER - DRAIN @ VENT - WATER (EA)
-
4 �..
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this mason
BACK FLOW PROMC`f. DEVICE a,...
!•
DE
SANITARY Y N
BECEIFT#
Owner DaeE
5
WORKMAN COMPEN DECLARATION
DRAINS - PLOOR;.R6OF, ANIiA, GOND.
SCHOOL TAX V
❑ Ihercby effiern that lhave acmificetete of ofco
mnummsdf-inxurc. oracmifcate of mXT1RE5-PL'R TRAP �\
Wmker%CompensmionlnsumnmorocenifiMcotry thereof(Sce. 380g1ab CJwhich. .` 9 8
covers all employ«s under this permit.
Policy # GAT- gS -1 �C.d OUTLETS'
./
RECEIPT#
PARK FEE Y N
#FEES
BUILDING DIVISION
Companyy, t
❑ Cenified copy is hereby furnished.
❑ Cenified copy is mad whh the city inspection division. �°
AS- ,SYTEM.OVFR4(A 9
`
G SPJINDUSTRL TEI
•"PLANCHECK
"'�
FEE
t
GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' '
GR SE TRAP
W
SOILS FEE
COMPENSATION INSURANCE 1
ENERGY FEE
(Thissation need not bemmpleted ifthe permit is for onehundred dollars (f 100) SEWER ITARY-STORM EA. 2001FTo-="-
or less.)
I cenify thin in the performunce of the work for which this permit ie issuW, I sludl
INMTER HEATI?R WryENT/ELECTR
not employ any person in any tanner so as to become subject m the Workea'
Compensatimlawesof California. Date
.. s'
,WATER SYSTEMtFRP.ATING
PAID
t Barrio #
TOTAL:
Applicant
NOTICETO APPLICANT: IL after making this Cenificam of Exemption, you ahwld NEW RESIDENTIAL PI-NIB.SQ. FT.
become subject to the Workers Compensation provisions of she Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed mvoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE 2 b
I hereby from Nat them is a contacted n loading agency for the Asa fmo unce ofELECTRIC
the sank for which this permit is issued (Sec. 309]. Civ. C.)
ME
PLUMBING FE
Lenders Name
Lenders Address QTY. MECHANICAL PERMIT
FEE
1 certify thin I have reuJ this application and state that the above information is
correct l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEF.
CONSTRUCTION TAX \
building construction, and hereby authorize representatives afthis city to enter upon the
above-memtoriol property, for inspection purposes.
ALTER OR ADD TO MECH.
(We) egrea m cave. indemnify and kap harmlas t ryof Cupertino against
liabilities,judgments,cosu endespenus which may in y wayaccmeagntrut said City
AIR HANDLING UNIT (TO 10,0011CFM)
f the granting afthis pemnll
l /��r�
-••i ('D'ata
AIR HANDLING UNIT (OVER 10,000 CFM)
PAID
tr EXHAUST HOOD(W/DUCT)
'igmtam of ApplicanUCunmcm
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UNIT (TO 100,000 BTU)
Date Rao tp
T TAL:
Will the applicant or future building occupant stare or handle hazmdoos mammal
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTIB
Coda Section 25532(.)1
11 Yen 13 No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
WilltheapplianlorfutumbuildingmeupmtuuequipmentordeviaswhicheMt
�acadrrsd
BOILER- COMP(3HP OR 100,000 BTU)
p `®
r
0 ��
a air contaminants u defined by the Bay A. Air Quality Manngemem BOILER - COMP(OVER IWW BTU)
-wictl
13 Yet 0 N NEW RESIDENTIAL MECH. SQ. FT.
1 have read the ba.Nous materials requirement. under Chapter 6,95 of the``
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that
11 H
�44 I `INU
ifthe building does not currently have a team. thin it is my responsibility to notify the
reentrant of the aquiremena which most be met prior m issuance of n Certif¢ate of
�1 �(v�[s
Gm V� V
ISSUED BY:
Owner or authorized agent Data
V
OFFICE