28370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-HLFICTNICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECBANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AlPPrrPPLICATIONSUBMITPALDAIE
W UNIT. LOl'N
OWN'RI NA E: PHONE: RA NAME: LIC NO:
s. Q LL r �O NIC ^C/O�NTRO..L✓.�.
RCHITECf/ENGINEER: Ll LIC NO:L? A r S ❑ ` ,/
it
CONTACT: PHONE: PERMIT
QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG F.LT PLUMB MECH
PERMIT ISSUANCE _Jf�yY`/ 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPIION
Omz Ihereby affirm Jul l am licensed underpmvisionsofChapter9(commencingwith
POO Sextant 70D0)of Division 3 ofthe Business and Professions Code.and my license is in PANELS
y�W full force and effect. UP 1'0200 AMPS
Q VZ License Class Lic.p
vFi¢a Date Contract. 201.1000 AMPS
f y Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.F'r.
ZOvs— OVER IWAMPS
I undemm�d my Plans shall be used as public rtcoNs. w O
Oz
pp�W
LicensdPProfessional SIGNS ELECTRICAL ■`/._Y
sad
uKl OWNER-exempt Ji die CoATION SPECIAL CIRCUIT/MISC.
50.d'O a V I ngmby affirm not f am exempt Jim Ne Con.a s Co e:Any
Law for the
1+13ay rllowtngteason.(Sectioslo3L5,Buslnr,iwdP as Code:Any city or county TEMP.METER OR POLE INST.
LL.Oa 'di,in
t requires n permit re cumvuc6 alter,i ave,dem fish,or repair any swemm
FYYfs�yo,7. pmm�miu issuance,also requires the am for such pe ism fil<asigned stmemem POWER DEVICES
0.JCQp
that he is licensed Pursuaas incisions of the Contra toes License Law(Chapler SWIMMING POOL,ELECTRIC 0..0.0 9 cu.a7(Sx)of Dishmn3afthe Bus essand Professions Cadc) /// VALUATION
W or that he is exempt therefrom and the basis for alleged emption.Any.iolation of OUTLETS-SWITCHES-FIXTURES ( ��
1_Z Section 1031.5 by any epplicam for a permit subjects Nee plicannm a civil penalty of v e OO
nm more than Bve hundred dollws(55110). NEW RESIDENTIAL ELECfR _SQ.FT.
C�' ❑ 1.asowuroftheprnperty.ormyemployeeswiN wage asshcirsolecompensatinn, STORIES TYPE CONSTRUCTION
a willdu the work.andtheswaure ianolintendedoroffereJr rsulc(Sw.1044,Business
sad Professions Code:1T Cantrn )'rP a Lew dnx not apply to an owner of
propenywhobuildsorim des n - such ark himxl(anhraughhis OCC.GROUP RES.UNITS
ownemploye41dor
cdth _ emesis menet int ndedoroffereA forsele.lf.
however, eem is eoldwiddrin ey ofcompletion,theowner.builder willm f Nat he did not buil or im rove for u se ofTo provin8 P P rWsale). .+lQTY. PLUMBING PIiRMIT FEEFLOOD ZONE APN
1,aaowproPenY•amexdusi onuadin withlicensedconuacmnm
construct the Project(sec.1044.B ass and Prafessi s Cade.)The Contractor's
Lire%J.awdoesnmapplytoa nerofpropcnywhobuildsmimpovestheneon,and PF.RMITISSUANCE
whasfm such prv' with econvamar(s)IicanxJ Punuem to the Contrnctoes
LivensmALav.Lew ALTER-DRAIN&VENT-WA'T'ER(13A7 FEE SUMMARY
'❑ 1a.exemP d<r Sec. ,B&P C for this eastern BACK MOW PROTECT'.pEVICE ID .E.
SANITARY Y N_
Owner Date DRAINS-FLOOR,ROOP.AREA.COND. RECLJ 'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
IherehyafOrm that l have a cesificate ofcmnxmm self-i...re.macenificaeaof FlXTURFS-PER TRAP RIC PT.
Work.Cimpensstion lmuunce ars certified copy themd'(Sm.38(10.Lab C.)which PARK FEE Y N
coverall di,plamil under this Prod. rsiliGAS-EA.sYSTEM-I INC O E IPTp
Policyat RUL INd O(VISION PEES
Company GAS-EA.SYSTEM-OV PLANCHF.CKF
ElCand!5tcopy is hereby famished.
❑ Cenilielcmpy is filed with the city inspeaiondivision GREASEIINDUSTRL WASTE I GRADINGF
CERTIFICATE EXEMPTION FROM WORKERS' GREASE'fRAP SOILS ME
COMPENSATION INSURANCE.
(This sexion need not be completed ifthe Permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. � ENT,RGY (EE
mless.)
I certify Wt in the perfm stirfthe workfar whichthispcmtit is issued,I shall WATER HEATER W/VENIELECTR
not employ any person in any manner so as m hceume subject r Ne Workers' PAID
Campensmion L,wsof Cnlifomia. Dam WATER SYSTEWREATING me Receipt.
O z Applicant
z 0 NOTICEI'0 APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rn became subject to the Workds Compensation provisions ofthe Labor Cade,you must
forthwith comply with such provisions or permit shall 4 deemed revoked. BUI NO FE
W �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a cotalruction landing agency for the performance of ELECTRIC E
O the wmkfor which this permit it issued(Sm.3091,Civ.C.)
Lender's Name
Q U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBIN FEE
U I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinance and state laws mixing to PERMIT ISSUANCE MECHAN AL FEE
U ,z building construction,and hereby amhorim representatives of this city to enter upon the CONSTR ION
T
am
bove- entioned pmpenpurposes,y for inspection puoses. ALTER OR ADD 10 MECI I.
(We).gree ro save,indemnify and kap hermleu the City of Calandra against
liabilities,judgments,coustad expenses whichmay in any way accrue against said City AIR HANDLING UNIT CFO 10,000 CFM)
in consequ ce of the grwurgoflhi I 1 / AIR HANDLING UNIT(OVER 10A0)CFM)
Si re ApplicwtV minr Dale EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dart R silt.
Will the the Cups or favor building le.Chapter 9.
or handle Healthy martnd
at defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,1X0 BTU) TOTAL:
Cade,section 25532(a)'t
13 Yes ❑No VENTILATION FAN(SINGLE RESID)
Will the applicant or fuwrebuidingoccpunfusee tri mem ordeviceswhich emit BOILER-COMP(31P OR IW, O BTI)
ISSUANCED T
banndom air contaminants as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,0011 BTU) P d
District? �Y A
❑Yes 13 No NEW RESIDENTIAL MECH. SQ.FT. U
1 have mad the heamdom materials requirements under Chapter 6.95 of the U` �8
Cnlifomia Health&Safety Cade,Sections 25505,8533 and 25534. 1 understand Net Ct/f 'A/�
if the building docs not comedy have a tamnt,that it is my responsibility to notify the Y r 9
m of the rtquiremenu which must h ma prior m issumre of n Cenificatc of
Occcupanu'ri cy. LVN•/ ..
Owner m uuthonr<d agent Data TOTAL: ISSUED BY:
L OFFICE