28427 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEPLUMIIING-MECHANICAL PLRMD NO.
BUILDING DIVISIONSION APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION 28427
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMDTAL DATE
/6,2-7 / �� IWITX LOTH
OWNER _ave plJ_ D�� CONTRACTOR'S NAME: LIC NO: 7
H I/�[' •f5' N/C CDNTROLp
['Ml'ECT/FNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: -' BUILDING PERMIT INFO
ELECIRIC PERMITS... •:� ::�. FEE n.•
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ � ❑
LICENSED CONTRACTOR'SDnsof DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
yT, Ih701ereby of Di Na l3 ofth Bu inns it ialomsofLTaode.an ommmcing with
7 Section)QIB)IT Divisionlof the Business end Professions Cada and my liens is in PANELS
mnlm e,den`1'3. 6 0
_y !sans Cl Lic.X D O IUP T02W AMPS
v: Del. Contmnm S 201-1000 AMPS ' r
n? ARCHITECTS DECLARATION OVER 1000 AMPS SO.FT.FLOOR AREA S/SQ.PT.
rz 1 undenund my plans shall Na used u public meem s.
W SIGNS ELECTRICAL
%j Licensed Professional
>:< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hemby affirm Nat 1 nn exempt form die Convectors Limns Paw for the
Q (allowing reason.(Section 1031.5,Business and Porfessioa Code:My city in county TEMP.METER OR POLE INST.
a, which mauves a permit m connrus,altcq improve,demolish or mPab any smendc
-2 Four to its immusen.also requires the eppliant for vuchpemiiUoftleasignWuuumut POWER DEVICES
Uro he is licensed pursuant m the provisions of Ne Contractor's Liccnx law(Chapter
Zw 9(commcncing with Section 10D(1af Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
-I- mdtu he laminator therefrom and Ne basis far the elle edmam a v.An
-0,, g p'o yvioletia of
Section 10313 by any applicant for a Permit subjau she applicant 10 a civil penally of OUTLET'S-SWITCHES-FIXTURFS
_.� trot more Nan five handrail dollen($50)),
❑ I.ssownmollheproprny,ormyemployaa withwegnnthevsolecompenxuion. NEWRFSIDENTIALELELTR _SQ.FT. STORIES TYPE CONSTRUCTION
-_ willdo Nework.and hestmnum isrmt imamdedoroffemd fmash(See.1014.Business
end Professions Code:The CO...Limae law does not apply no sm owner of
property who builds or improves Merton,and whodoes such work himslfor through his
roar employee,provided that such imProvemenu am am roundied mattered intrude.If, OCC.GROUP RES.UNITS
however,lie building or improvement is sold withmmin yeerofeemph,dar,m,owncr- TOTAL:
builder will have be burden of proving that he did not Initial improve(m Inartistic of
❑ Luowv<r of Ne n amexdusivel conwdin t Y �' ,.F. APN
porpe y Y gwithlicaxdcmmctomo ' -•'' ••'%- BING PERMIT.,,ry^aj- ,[ nA.(,_FEE FLOOD ZONE
comvun the Inject(Sec.1044,Business atm Professiav Code:)The COorrector's
Limmelfms"applymanownnofpmper$)Iimn ildamimito ec Cereon,and PERMIT ISSUANCE
whoconvactx(orsmh projau wiNecantucmr(OlittnsM pursuantto Ne Convector's 'rn.:...• �.
License law. ALTER-DRAW&VENT-WATER IEA) ._e i;•�-;;.,r FEE SUMMARY,(•.
E31 am mcmp aaltt Sec, ,B&P C fm Nis mason
BACK FLOW PROTECT.DEVICE SANITARY Y N
Date DRAINS-FLOOR ROOF.AREA,COND. RECEIPT'X
tt WORKMAN COMPENSATION DECLARATION SCHOOLTA)( YN
Iimalry Rum Nullave,ani0ute of consmno slf-insure,araanifiute of FIXTURES PER TRAP / RECEIPI'a
mkas'Campevadon laurence Oraanifiedcopy themef(Sec.3B00,Lab C.)which PARK FEE YN
coven all cmployeee under this pentdt. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT a
PoItryN BUILDING DIVISION FEES
�^Car ifiedcopy is hereby fumisM1ed. GAS-EA.SYSTEM43VER 4(EA) PLANCHECK FEE
❑ fen
❑ CmiBed copy,is fled with the city inspection division. GREASEONDUSIRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notba completed ifthe permit is fortune hundred dolurs(SIW) SEWER-SANITARY-STORM EA.30OFr. ENERGYME
or leas.)
I cmify Nat in the prfonnance of the woh for which this pemdt is issued,I met WATER HEATER W/VENTIELECTR
not employ any fiction in any remover so as to became subject to the Workers IPAID
Compormlim Lw
asof Celifomia. Dae ATFRS TEM/IREkTING Data ReceiptN
Applicant
NOTICE TO APPLICANT.If.after making this Cmifcate of Exmpion,you shout IDENTIAL PLMB. SQ. .TOTAL:
became subject m the Worker's Compensation provisions of the Labor Cade,you mum
forthwith comply with such Provisions or Nis permit shell be dimmed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hmby air=that here is a cwrsvuction lending agency for she performance of
she work for which this permit is issued(Sec.3091,Civ.C.) T ` ELECTRIC FEE
Lender's Name
1<ndc/s Address QTY. X 'r;iMECHANICAL PERMIT FEE-rH' PLUMBING FEEwto
1 amity Nm 1 have rad this application and sum that the above information is s"
correct.legrce to comply with ell city and rounry ordinances end state laws rclauinpm PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize mpommutives of Nis city to eructation the CONSTRUCTION TAX
_ above-mentioned progeny(m ryos
inspection pus. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hamiless the City of CuPenino Midair
liabditin,judgments,costs andexpenus which may in any way xcruc against aid City AIR HANDLING UNIT(TO 10,000 CFM)
in conscquace of the Branding of this permit.
AIR HANDLING UNIT(OVER 10,00)CFM)
Signature of Appham/Catracter pure EXHAUSTHOOD(WIDUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO V11100 BTU) Dam Receipp
Will the applicant or fumm building mcupsm Stam or handle humdaa material
ss def red by the Cupertino Municipal Code,Cha cer 9.12,and the Health and Safety HEATING UNIT(OVER 100.010 BTU) IAL:
Code.Section 255321aR
❑Yes 13 No VENTILATION FAN(SINGLE REBID)
Will air communities
as building occupantum equipment Quality
Management
BOILER-COMP DHP OR 100.000 BTU) ISSUANCE DATE
rdous air conteminenu ss defined by the Bey Arse Air Quality Menagcmem
tsar+ BOILER-COMP(OVER100,000BTU) �. A E
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Fr.
1 have read the hamundSafety
Code,
merlons require 5533 under M.I un erst of the JUL 1 a• -AO C
California m,du&Safely Coda Smions 25505.Z5533 and 25534.1 understand Wt V Y KRJaLYtljly J
if uhe huilding doesn cu rely hvrc aKit is my no to notify the
oecupmt of the is whi unrim to issuance of a rdfcme of r I INC)
O c rears
s
Owner o aathomud agent Dau TOTAL: ISSUED BY:
OFFICE