27100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB .DI 1L6 OHCAI PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL I 'I 00
BUII.DIN(.PROJEC'iDENI'1F'ICA'TION / 1
BUILDING AD/D�RUSS: o ��./ SANITARY NO. APPLICATIONS BMfITAL DATE
C�2ic^ems �� UNITN LOTH O
OWN' NAly i:� HONE: CO ACTORjS NA.Mle: � �LICIJ0:
--NIC O L
RCHHUCT/ENGINEER: LIC NO: ADDRESS: �,�0� ❑
, I 'ONTACT: PHONE: QTY.TY.1 ELECTRIC PERMIT FEB BUILDING PERMIT INFO
\vv�
PERMIT ISSUANCE 1:1 El
BLDG ELECT PLUMB
MCH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
QWzI hemb ffimiM1 tlamlicenx uMer mvisiomof Ch 1 9(co orcin th JOB DESCRIPTION
POO f P ep cr eI.
1x100 Swtion 9000)n(Division3nf Ne Businaaend Professions Calc,end my license is in PANELS
FC w full force end
V G 2�°2o�3b � UP T02 AMPS
GZ Licenu Itus Lic.N
y6P- Data Convects 201-IIXIO AMPS
f—y Z_ ARCHITECTS DECLARATION SQ.P .GOR AREA E/SQ.Ff.
OZ-t] Iunderanal my p]ua,,Jall be used As public records. OVER IOOOAMPS
F yr J SIGNS ELECTRICAL
6 �U Licensed ProPossionel OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KKOYYa11U I hereby affirm that 1 ern exempt from the Contractor's License Law for the
RO a fallowing reason.(Section'1031.R Business and Professions Cade:Any city or county TEMP.METER OR POL8INST.
J which reyuGea A permit to conswn,Aber,improve,demolish,or repair any atrvnum
;!IY� prior to its issuance,also mquires the applicant for such permit to file a signed a"ument POWER DEVICES
IS.
re: p that he is licensed pursuwna the Provisions of the Contractors License law(Chapter
daAd �1 9(mounnA eing with Scetion 1000)of Division 3ofMA Business And9o(ession,Coda) SWIMMING POOL ELECTRIC VALUATION
Indian he is exempt bemfrom And the basis for the Alleged exemption.Any violation of
[— Q Scetio,9031.5 by any applicant for a permit subjects the Applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
's nod more than Eva hundred dollars($SW). NEW RESIDENTIAL ELECTR SQ.FT.
7y p ❑ LssowaemfNndred dy,army500), eawiNwagesmnheirwlccompemelion, STORIES TYPE CONSTRUCTION
y3e= will do the work,and the structure is not intended or offered for sale(Sm. Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,And whodoes such wad Almulfor through his
own cmpllyen,providM,hunuch improvememaArt nal in¢nJedoroffercd fOrsele.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within on"Acrofcompledion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
W0')' QTY. LUMBING :R E
❑ 1,as ownerafnhe property,Am exclusively contracting with licensed contreenomo FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions CodeO no Contractors
License Lawdoes notapply manawnerofproperty,whobuildsarimprwaaMemon,and ERMIT ISSUANCE
who contracts for such projectswith A condo mr(s)Iwensedpursuanuodhe Convectors se Law.
License
LTI?R-D & -WATER(PA) 1 FEE SUMMARY
I] l um exempt undo Sec. ,B&P C for this return B CK 0 CT.DEV CE OUTSIDE
SANITARY Y N
Owner Dam RECFIPT#
DRA S-Fl. , OOT,AR
_ mfttlWORKMAN COMPINSATIONDECLARATION SCHOOL TAX Y N
I ❑ thmba,s'Cu effvdn thi Immance inificati r cup,thereof
LabaceC.))cmed F1XTU -PER p PARK HE YECEIPI'4 N
Wmkeri Comlxnsmiun Insurance or acenifiul copy thereof(Sec.3800.Lob CJ which RECEIPT 4
covers ell employce'sundcr tJ�gpa ou G�/J �,!_y 6 GAS-EA. YSTEM-I INC.40 S BUILDING DIVISION FEES
PalicyN /V O 7
Company 1�4rr� I� GAS-EA.S TEM-OVER 'A) PLANCHECK FEE
❑minified copy is hereby fumiahed.
Zr Criificd copy is filed with the cily inspection division. OR F7 A SEANDT JSNle<A SM INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifdhe Permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.290FT. ENERGY FEE
tole".)
Icenify that in the perfomanccofthe work far which this permit is issued,I Shell WATER HEATER W/VPNT/ELECIR
not employ Any person in say manner so us w become subject to the Workers' PAID
Compensationlawsrf Celifomia. Date WATER SYSTEMITRHAMIG Dade Receipt#
'Z Applicant
z � NOTICE TO APPLICANT:If,after making this Certificate of Exemption you should NEW RES]DFNTIAL PLMB. SQ.IT. TOTAL:
p] become subjceno the Worker's Compensation provisions of the labor Code,you most
P 5 foNtwith comply with such provisions or this pcmdt shell be damned revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affimt that them is A comwction lending agency for the pMarmomm of
U O TOTAL: ELECTRIC FEE
the work for which this permit is issued(Sm.109'/,Civ.C.)
Lender's Name
0 � Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
W4 I certify thin 1 have read this application and state that Ne shove information is MECHANICAL FEE
convict, l agree to comply with ell city and county ordinances end"ate laws rtlatingro PERMIT ISSUANCE
OG building construction,and hereby authorize representatives of this city m enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECH,
(We)Agree ro save,indemnify And keep harmless the City of Cupertino against
lamilidic,judgmen".cmts andexpemes which may in Any way accrue...untold City AIR HANDLING UNIT(TO 10,001)CFM)
in consequence of the gmnning of this permit.
AIR HANDLING UNIT(OVER I0,OfI(1 CFM)
Signature of Applsaal/Cammcter Date EXHAUST HOOD(W/DUCT) PAID
IIAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IWXXXI BTU) Dau Receipt#
Will the the Cupnt or ertino u bupding Coade. gamer re 9.2,hanand the
hmaNh andous Safety HEATING UNII'(OVER 100,000 BTU) TOTAL:'
al
tu defined Ey the Cupertino Municipal Cade.Chapter 9.12,end the Hea11h and Safety
Cale,Section 25532(o)1 VENTILATION PAN(SINGLE RE9ID)
❑Yea ❑No
BOILER-COME(3HP OR 1(0,0011 BTU) r�ISSUANCE DA
Will nAir co t a manus As de nee by the Bay a m.Ain Quality
cManagM1 emit (f9( F �y,
haxartlous air contaminants tu defined by the Bey Arte Air Quality Merugement BOILER-COMP(OVER If0,IX108TU) 4 f.Y
[MmctP ®CT
❑Yn ❑Na NEW RLSIOENW.TMECH. SQ.PT. �
1 hove mid the lawoodous materials bapiremenns under Chapter 6.95 of the Clly 1994
California Health At Safety Code,Sections 25505,25533 and25534.Imakatandthet / (�
if the buddig nmmrmndyhav ten t.that it is my maponsibilirym notify the rVur
th Arm ents 0 1 t met Prior to issuance of a Cervi I..of CNIIryU
aeaP y `p
O rut arixed agent Date L. ISSUED BY:
OFFICE