27595 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBIN•. 'I. PERMITNo. [^ 5 9
BUILDING DIVISION APPLICATION/PERMIT G-MECHANICAL 9
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: uI SANITARY NO. APPLICATIONSUBM�ITTTAALDATE
ca& e-T- UNIT# LOT# Ir `7
OWNER N CONTRACTOR'S NAME: LIC NO: ` 1
�- O N/C CONTROL#
C TF.C' N Nli• LI ADDRESS: ❑ �
CONTACT: yFIpNBf 'f- F-C '-',S.'.
/VQ' rr QTY I+/'t XA4FL xIC PERMIT- FEE BUILDING PERMIT INFO
ELECT� PL� .1MECH
'1
[/K 0 / PERMff ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
O PCZ I hereby affirm that l ma licensedunderprovisionsofChapt«9(cammenciagwith
1400 Section 7000).f Division 3 of the Business and Professions Code,and my license is in PANELS
�tY]E ruemmeanderfen.
F,2tD License Class Lo.as UP TO 2W AMPS {/
Qy Date Convector 201-IOW AMPS 4
Z OF�3 ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR A T $/SQ.Ff.
O Z-•qqqq 1 understand my plans shell be used ss public notim s. — e e /A
F'y�� SIGNS ELECTRICAL /(Dt15 40.
q' Dressed Professional
�J < that
I ma exempt Rm the CoATION SPECIAL CIRCUR/MISC. /r
°•OtyI, I hereby,Trina,that 1 am exempt harem the Convutors License law for the
3 O h following reason,(Section TOJLS,Business and Professions Code:Any city or county TEMP.METER OR POLE(NST, hV
h which requires a permit to consuua,alter,improve,demolish,m repair any structure,
;!(Y� PHono asissuanre,also require Ne applicant fmauch permit m file a signedsaorment POWER DEVICES
vp_�OK ilia,he is licensed pursuant o the provisions Orth,Contactors License Law(Chapter
a oa4 9(commencing with Section T000)of Division 3 efthe Busineuand professions Cade) SWIMMING POOL ELECTRIC ^ VALUATION �.
yYj_y orthat n7031. bymympt refromsund thentfar.bodstsubjfor easegedp,licaexemption.Any ivilPoationof OUTLETS 331
F-Za not mr.than
five
emndred do]] ($50 mnit subjects the epplicanuoacivilprnally of `
sTs�
not more than rofihepmddollus yam). Son\
CC0 ❑ I,mowneroOhepropeny,ormyempinyees withwegesmtheirnolecompenmtivn, NEW RE9IDENTIAL 5LEC9R _SQ.PI'. STORIES TYPE CONSTRUCTION
aa$ willdo the work.snd the mucture isnot intended mothered forsale(Sm.7044,Business e
and Professions Cole:The Contractors License law doss not apply in an owner of
propenywhobuildsorimpmvesthereon,mdwhodmssuchwonkhitn«Ifonhmughhis OCC GROUP RES.UNITS
own employees,provided that such i mprovemrna are not intendedm offered hostile.If,
however,the building or improvement is sold within one yemofeampletion,theowner-
builder will have the burden of proving Nat he did not build or improve for purpose of
.It.). . .. ' ..
C] L asowner ofthe property,am exclusively contracting with licensed contrctorto Q�' j',PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.704,0,Business and Professions Code:)The ConvectNs PERMIT ISSUANCE
License Law does notapply toanownerofpropeny whobuildsm improves thereon.and
who contracts forsuch projects with acomractofa)licensed pursuant to the Convenors ALTER (EA)License Law. FEE SUMMARY
❑ I om exempt under Sec. ,R&P C far this meson BACK PLOW PROTECT.DEVIFE SANITARY YIN
Dene DRAINS-FLOORR ILEA,COND. RECEIPT#
,
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX Y
I hertby affirn thetlhaveattnifimre ofcmuntaelf-insure.maurtificate of NXTUM PER RECEIPTp
Workers Compcnsntirnlnsumrae orncenified copy thereof(S«.38W,Leb CJ which PARK FEE N
coven all employee's under this permit. GAS-EA.SYSTEM-VC.401 5 EC I
Pot cy# BD ON FEES
Company GAS-EA.SYSTEM-OVER (F ) PLANCHECK
❑ Certified copy is hereby fsmishm.
❑ Cenificd copy is film with Ne city inspection division. GREASEONDUSTRL WA FPf GRA
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS E
COMPENSATION INSURANCE
(ibis section n«door becompleted if the permit is(manehundrmdollan(fled) SEWER-SANITARY-STORMFA.200FT. ENERGY FEE
orless.)
(certify thatin Ne performance of the work fm which Niepermit is issum,lshall WATER HEATFR W/VENDELECTR
not employ any person in any maim«sar u in become subject to the Worker' PAID
Compenwtionlawsaf Celifomia. Dam WATER SYSTEMIMEATING Date «,ipt#
Z O NOTICETOAPPLICANT:IL afar makingthis Cedifimaof Esmphoes,you should NEW RESIDENTIAL PLMB. SQ.FT.
p TAC:
'Z s^Ln. become eubjen to the Workers Compensetim provisivna of the Lehr Code,you must
7 forthwith comply with such Provisionsor this pemdt shall be deemed revoked. BU
ILD Mks
r4, CONSTRUCTIONLENDINGAGENCY SI O'
(hereby affirn that there is a construction lending agency for Ne performance of T
V O the work for which this permit is issued(Sec.3007,Civ.CJ ELE `
Lenders Name 777
u" Lenders AddressQ'17:1 •;w"MECHANICALPrRMlT FEE PLU GFEE ILIA
O I certify that I have read this application and nate that the native InfO1ma401118 :. ':. ,
OW-t torted.l agree to comply with all city and county commonest and show laws relating a PERMIT ISSUANCE MECHANICAL E
y hallding construction.and hereby amhorize repmsenatives ofmas city to enterupon the CONSTRULTI TAX
V Z above-mentioned propeny for inspection purposes. ALTERORADDTOMECH.
(We)egrs m save,indemnify and keep harmless Ne Ciry of Cupertino alnst
liabiline,,jud ms,costsand a whichmayinrnywayaccica Zi 4,i City AIR HANDLING UNIT(TO tOAW CFM) Ilk
in const u fNe grnti _'dr
fNpermit.
�. AIR HANDLING UNIT(OVER 10."CFM)
of ApplicaraW D EXHAUST HOOD(WMUCI')
PAID
H GUS MATERIALS DISCLOSURE FEATINO UNIT(TO 100,008 BTU) Dam Rattipt#
Will the applicam or future building occupant more or handle hmaWous material ITEATINO UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health aM Safety
Code,Section 25532(ti)?
El Yes ❑No VENTILATION FAN(SINGLE REBID)
ISSUANCE DATE
Will theapplicantorfum «
mbuilJingsvpenqui
t use cpmentordeviceswhich,mit BOILER-COMP(3HP OR IM,"BTU)
anrdous air cotnannimnts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 103,000 BTU) qq��
'strict? ❑ ❑ g� p
Yes No � NEW RESIDENTIAL MECH. SQ.FT. 4,.1 BO
I have read the humadcas materials requirements under Chapter 6.95 of the k/l/a00
�Celifomia Health&Safety Code.Sections 255D5,25533 and 35534. l mdenand that .a
ifthe building does not currently have a tenant,that it is my responsibility to notify the y. /
occupant of the requirements which must be met prior to issuance of a Certificate of �Ir (s/
Occupancy. r(#
Owner or uuthorized agem Date T ISSUED BY:
OFFICE