30613 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. . �O
BUILDING DIVISION -APPLICATIONIPERMIT a PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
613
BUILDING ADDRESS: s`AI A/I C A 0 SANITARY NO. APPLICATION SUBMITTAL DATE
/090/ Al Oe zp, BLVQ avo — � .
OWNER'S NAME: PHONE: CONTRACTOR'SN ME: LIC NO:
g / r N/C COME tOL x
LIC NO
\RCHIT.Ct/ENGINE•[R: : ADD ESS O
C- 6 �o
CONTACT. PHONE: _ BUILDING PERMIT INFO
u' V D Nw.Sefv a_ / ❑ Consultant FEES,Puld by Applicant(InINBI) B ELECT PMECH
te
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby aRrm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
G00 with Section 7")of Division Sof the Business and Professions Code,and my license is RESIDENTIAL:
�kuO in Q PERMIT ISSUANCE
Pone Class and ellen. [ �! 7 rs' ❑SFDWL [I KITCHEN REMODEL
�k.UUU LiceGore Class Lic.fl APPLIANCES-RESIDENTIAL CADDITION [:I PLUMBING RE-PIPE
.
N D 6 Date Commaor
lo, ARCHITECT'S DECLARATI N ❑MULTI-UNIT ❑STRUCTURAL
ZOI�i4 I understand my plans shall be used as public records PANELS MODIFICATION
0,4.x., UP TO 200 AMPS C3 INTERIOR [ICHIMNEY REPAIR
r-no E. Licensed Professional 201-100CAMPS IMPROVEMENT `
pg OWNER-BUILDER DECLARATION OVER IIXIO AMPS [I BATH REMODEI/REPAIR [I DEMOLITION
OL 1 hereby affirm that I aen exempt from the Contra rr is License Law for the
OyUany improve,demolish,or following reason.(Section 7031.5,Business and Professions CWe:Any city or county SIGNS ELECTRICAL
0 ❑GTHER
a y which requires a permit to isa suaa,eller, repair metre
I-'� g priormits issuance,also requires the eppliamfor such pemtitmBleesignW stamment 'PECIALCIRCUIT/MISC. Drit
that he is licensed pursuant to the provisions of the Conuonnr's License Law(Chapmr9
(commencing with Section 7000)of Division 3 afthe Business and Professions Coca)or 'FEMA.MIOER OR POLE INST. 19
MMERCIAL-
It.6 c oOC that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
x t+•tD�
Section 7031.5 byanyapplicam tons"ra itsubjtsiume applicant toucivilpcnattyof POWER DEVICES tn L ANT ❑FWD SERVICE
Zp, tmnrc than Eve hundred dollars(5500). f// IMPROVEMENT
Q C 1,as owner of the property,on my employees with wages as their sole compensation, SWIMMING POOL ELF. RI (
will do the work,and the nmmunu is not intended oroffemd for sale Edec 7EUw Hueinese ❑OTHER
R1 and Professions Cade:The Cmumaors License Law does not apply tee am owner ofUTLETS-SWITCHES RES
6 a^ pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided monsoon improvements am nut intended or offered for NEW RESIDENTIAL ELECT t Q FT.
sale.If,however the buildingor improvement issuld within one year ofeempledurt.theSQ.F.FLOORARHA S/SQ.IT.
owner-builder will have the burden of proving that M1e did not build Or improve for par- M
C 1,as owner of the propeny,am rom exclusively nuacting with licensed contractors TA,so of
construct Ne project(See 7044.Business and Professions Cale.,The Contmcmrs Li- Y
ase Law does not apply to an owner ofprepeny,who builds or improves nation,and QTY. PLUMBINGPERMI FEE -
who comtmen for such Projects with a conuaaooti)licensed pimmunt to the Contractor's
License Law, PERMIT ISSUANCE
❑I mat exempt under Sec. .B A P C fur thio Itasca
owner Date
ALTER-DRAIN&VENT-WATER(HAL A, O
WORnderPenalty
COMPENSATIOn DECLARATION BACK FLOW PROTECT.DEVICE
I he"by stria.n ism Cerin rale fCorwam of serf-m nefor d¢buations:
ti ❑or.as andwientfor m Studio.377 of the LabmCode far theIWmkrouCompen- DRAINS-Fl.00R.ROOHAREA,COND. STORIES TYPE CONSTRUCTION
murk,as provides for mi Ss issued,
3?00 of the Lahnr Cale,for the performance Of the 1 I s PQ I'/I` +I
wad for ty ad tilispenniin issued. - FIXTURES-PER TRAP V '�,i -
1 hove and will maintain Wodror Cmme of
Insurance,h required t i Section -
TlOO of the lahorCWgfar the performance mf the work for which this hermit is issue). GAS-F.A.SYSTEM-I INC.40UTLE1'S .00C.GROUP _ APN
My Work erq Cor�peys�iogJnSul'aIlS.c rand Policy number e G
Carrier. AL Polity N, Z A /r 21901 GAS-EA.SYSTEM OVER 4(EA) /rte
xr CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS[/INDUSTRL WASTE INTERCEPTOR N
COMPENSATION INSURANCE B DIVISIONFEES
(Thu section near not be completed lfthe permit is foto e,hundred dollars($IN))
GREASETRAP
ar less.) PLANCHECK I. C
I certify Natimhe perfmnner o as twncomesuiject it)peemitisiss Compa11 SEWER-SANITARY-STORM EA.200 FT.
nut employ any person in any manner sat az to beeame suhjecuo the Workers Compen- ENERGY �
zz scion Taws of California.Date WATER HEATER WNENT/ELEC It
Applicant GRADIN
ti NOTICE TO APPLICANT.IL after making this Cenifcate of Exemption,you should WATER SYSTEMODEATI NG -
abecome subjeeuo1Ib Workefs Compensation provisions of the labor Code.you muse SOILS FILE
Lk1 fonhwieh comply with such pravisionn onhis permit strait bedcemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ.PI'. PAID pate Receipt
V 0 I hereby affirm that there is o construction lending agency for the performance of
to work for which this permit is issued(Sec.3097,Civ.C.)
E-' Landry'.Name TOTAL:
O V
W Lender',Address TOTAL:
I certify that I have Ovalmi,application and stun that the about information iBUILDING FEE
s
V) correct.)agree tocomply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V 7 building construction,and hereby randomize representatives ofthis city to enter upon the SEISMIC FEE
.11
above-mentioned prepeny for inspection proposes. PERMIT ISSUANCE.
(We)agree to save,imlemoify end keep harmless Ne City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way uttme against said City ALTER OR ADD TO MECH.
I.consequence of the granting of this pernil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL.HESOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of Apphcant/Contmcmr .Dae FXHAUST HOOD DODUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicant Or future building occupant smrem handle haricubms material HEATING UNIT TIO 100,000 BTU) _
as defined by the Cupertino Municipal Cal,Chapter 9.12,and the Health and Safety - -
Code,Section 25532(,)7 HEATING UNIT(OVER 1 W,00so SITE)
❑Yes .4No VENTILATION PAN(SINGLE RESID) PAID
Data Re<ciptp
Will the applicant Or future building occupant use equipment or devices which BOILER-COMP OHP OR 100,0(10 BTU)
m -
erat hardos uair conturarmas as defined! the Bay Area Air Quality Managemedl TOTAL:
e Duto"? d`'� BOILER-COME(OVER 100,000 BTU)
❑Yes Fes,
I have read thew
laohm,maeruts acquirements under Chapter o95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forms Health&Safety Cede.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH.
.tanking c1ces..curently have,tenant,that it is my resgo sibilay mma fy the ascupant
of Wt ms hit man be met prionoissumece ofa Cenikcate of Qeupanc
Owner ora i Date TOTAL: ISSUED BY:
OFFICE ��
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDINf,-ELECTRICAL PERMIT NO.
BUILDING DIVISION _ APPLICATION/PER�IIT PLUafnlrr,-hlECunmOAL 3061:
BNLDING PROJECT IDENTIFlCATION
BUILDING ADDRESS. .SU.✓ d(IC/LO SANITARY NO. APPLICATION SUBh11TTAL DA
/O ao/ Al De z BLUO Av So Ira %
OWNER'SNAME: PHONE: CONTRACTOR'SN ME: LIC NO: ylC CONTROL as
• ARCHIT.CDENGINEER'. LIC NO: ADD ESS qs/Q El
H OK C- b P'O 'V1 n_,) CV" v
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Pais)by Applicant(initial)6>ABLDG ELECT P MECH v( _Q'gPA,6141 -Y/S9[b- 83i
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affml than 1'am licenud undo pookioos of Chapan 9 anmoacramg
'CMZ with Settle.70001.1 Division 3afihe B.,inessand Rnhssiam Che,and my license i. RESIDENTIAL'
IJ C Q PERMIT ISSUANCE
(-•..0
1.cene Cli and e(ka. LY r 9�s ❑SFDWL ❑KITCHEN REMODEL
aUV
License Class Lica APPLIANCES-RESIDENTIAL El ADDITION C1 PLUMBING RE-PIPE
Z W Date Contractor :Xj) f
Ca
❑MULTIUNIT ❑STRUCTURAL
F>y ARCHITECT'S DECLARATION PANELS
OZr-/�_Z I understand my plan—hall be used as public mcmde UP TO 100 INTERIOR ❑MODIFICATIONMODIFICATIONCATION
❑ CHIMNEY REPAIR
<�F'L (X)Licensed Proms.mm.I 81IIlXlB AAIPS IMPROVEMENT
y f OWNER-BUILDER DECLARATION OVER IlXN1AMP5 ❑BATH REMODEIIREPAIR ❑DEMOLITION
x Q 1 hereby affirm that I am exempt Item the Cmamemn's License Law for the
X3 a U following reason.(Section 7031.5.Business and Profesaiom Code:Any city ar county SIGNS ELECTRICAL 'i / OTHER
a X which requires a perit to enu
nsi m.alien,improve,demoh,lb.or repair any structureF�Ogl mpnor to its louance.'also requires the applicant for such Permit to file a signed slaenant PECIALCIRCUIT/MISC.
DX
f.y„ Ihahnisfocussed puremnnothe of Division 3 Business
and
Prm Law is Capar9
W CC Bar he is crgwith Section7000)of basis
nr the alegedcmarxm.Anyovi Codes or TEMPM ETEROR POLE(NST.
a a e Y that he is cumpt Iherefmm and me basis for me alleges ewmmmn.Any violation of � NEW BLDG/ADDITION ❑DEMOLITION
W=n Section 7031.5 by any applicant for a permit subjects the applicant toaeivilpnall,of POWERDEVICLS NANT ❑FOODSERVICE
~?Sof more than fine humored dnllas D50B). ' IMPROVEMENT
D Lm owner of the employ,or my employees with wages as theirsule cooperation. SWIMMING POOL ELECTRIC
aF.0 willdolhe work.and the structure is not imandedoroffercdforsole(Sce 1014.Business ,OTHER
W �_ anJ proma nos Cade:The Commerce,License Law does not apply,.an owner of UTLETS-SWITCHES-FIXTURES
e'3 property who builds or improves thereon,and who does such walk himself or though
his own employees,provided Nat such impmvemcnts are not intended or ahead for NEW RESIDENTIAL ELECTR SQ FT.
s.It.If.howea<n.the buildingorimpmveoem issoldwithinoxyearafcompleiandbe SQ.FT.FLOOR AREA SISQFT.
.
onn
or-builder will have the burden of proving that he did not build or improve for par-
Pau of sale.). TOTAL:
❑ 1,as owner of the prapeny.am exclusively contracting with licensed comments to 1 ✓� a> \J v
onsauct The p.jet,(Sec.1044.B.dm as and professi.ns Cadet The Comment,s Li.
cense law does not apply to an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
whoconuacts for such finance,with a comrucmns)licenud arromauo the Contractor's
License Law, erasarr ISSUANCE
❑ I ore exempt under 511. -
A O
Owner /
Wm under WORKER'SCOMPENSATION of
I hereby off under penalty bof eperjury ane of ( U
❑Ihvve and will mainmina Ccnifcate of Conum m: -L. 1 TYPE CONSTRUCT'
smion,as provided for by Section 37M of the Labor I / �/N-'1� �/s Pe IA'i
w.h for whicM1 this permit is issued.
❑ 1 ore and will moinmin Workers Compensation'
3100 of the Labor Code.for The perfomunce of the ws APN
My Workers Chat menutioNnVtEagcEcarrier and
Casricr.T� Policyy Is h F
se/
CERTIFICATEEXEMPTION Fl
COMPENSATION INSUI
(VISION FEES.'XSy'^';}a
Nor less.lIThrncednatbecompBins,pem
lsnify Thanin hebenfamlanc..ftae
warkh
not employ any person in any manner so as to occur
Z smarm Laws of Califomia.Dam
O O Applicant
Z NOTICE TO APPLICANT:IL after making this C
became subject to the Workers Cosmo penuuan por /
forthwith comply with IncCONSTRUCTION
ION LE Dd 7I�d I ,\ .tea
0. � CONSTRUCI'IONLENDI l/l((I�l /
V O I Imomyaffirm that them iso cmarmaion l ReceiPl
F the work far which this peonn is iuued(Sec.AN
O Linters Name TOTAL:��
L) Lever Address
F0- 1 certify thus 1 have read this appiumian t
N coven.I agree,.ma.Ply with all city and county ordiwraex
V Z building construction,coal hereby umh.dm mpmecraives of this city m enter upon the
obovememioned Property I'or inspection purpous. ERMIT ISSUANCE S
(Wed agree In save,indemnify and keep harmless the City of Cupertino against ELCllnn..._
Iixbilities.judgmenu,cans and expenses which may in any way accuse against said City gLTER UR ADD TO MECH PLUMBING FEE
in consequence of the granting of this fic mal.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFMI MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.01X1 CFM( CONSTRUCTION TAX
Sigrommaf Apfil.m Conaacbm Dare EXHAUST HOOD IWIDUCT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant seem arbandle haavrdous manna) ((EATING UNIT TTD IIMI,UIXI BT1JI
as delind by the Cabochon Municipal Code.Chapter 9.11.and the Health and Sa cty HEAPING UNIT(OVER HMI.IXXI pTl➢
Cade.section 25532(a'? �-/
❑YesNn VENTILATION FANiSIN'GLE RESIDI PAID
• Dale RCCIPI II
Will the applicant or rowrc building occupant um egmpmenl ser de vices which pO1LER-COMPIlIIPfIR IplI.(MM)pTtil
emit hoombous as commodities as defned by the Bay Area Air Quality M hc,'I cm TOTAL:
District I BOILER-COMP IOVER IIM.000ITTU I
❑Yes
I have mature hvmloos maerwls apartment,um4r Chapter 6.95 of Be Cali AIR C(INDIT1f1NER I ISSUANCE DATE
hnnia Health hit Sony Code.Sections 25505.3533 and 155N.1 urukrsund that if the NEW RESIDENTIAL MECII. 5Q-IT.
hadding does net currently have a tenant.fha a is my mapmsibil'ry 1.notify the tuvvp:mt
nl the vire hie must be Our pnnnniuuawe tel aC'cmlieate of OcnuPaL
Uwnenu sew m Dam TOTAL: ISSUED BY:
ID F i C
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. . �O
BUILDING DIVISION -APPLICATIONIPERMIT a PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
613
BUILDING ADDRESS: s`AI A/I C A 0 SANITARY NO. APPLICATION SUBMITTAL DATE
/090/ Al Oe zp, BLVQ avo — � .
OWNER'S NAME: PHONE: CONTRACTOR'SN ME: LIC NO:
g / r N/C COME tOL x
LIC NO
\RCHIT.Ct/ENGINE•[R: : ADD ESS O
C- 6 �o
CONTACT. PHONE: _ BUILDING PERMIT INFO
u' V D Nw.Sefv a_ / ❑ Consultant FEES,Puld by Applicant(InINBI) B ELECT PMECH
te
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby aRrm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
G00 with Section 7")of Division Sof the Business and Professions Code,and my license is RESIDENTIAL:
�kuO in Q PERMIT ISSUANCE
Pone Class and ellen. [ �! 7 rs' ❑SFDWL [I KITCHEN REMODEL
�k.UUU LiceGore Class Lic.fl APPLIANCES-RESIDENTIAL CADDITION [:I PLUMBING RE-PIPE
.
N D 6 Date Commaor
lo, ARCHITECT'S DECLARATI N ❑MULTI-UNIT ❑STRUCTURAL
ZOI�i4 I understand my plans shall be used as public records PANELS MODIFICATION
0,4.x., UP TO 200 AMPS C3 INTERIOR [ICHIMNEY REPAIR
r-no E. Licensed Professional 201-100CAMPS IMPROVEMENT `
pg OWNER-BUILDER DECLARATION OVER IIXIO AMPS [I BATH REMODEI/REPAIR [I DEMOLITION
OL 1 hereby affirm that I aen exempt from the Contra rr is License Law for the
OyUany improve,demolish,or following reason.(Section 7031.5,Business and Professions CWe:Any city or county SIGNS ELECTRICAL
0 ❑GTHER
a y which requires a permit to isa suaa,eller, repair metre
I-'� g priormits issuance,also requires the eppliamfor such pemtitmBleesignW stamment 'PECIALCIRCUIT/MISC. Drit
that he is licensed pursuant to the provisions of the Conuonnr's License Law(Chapmr9
(commencing with Section 7000)of Division 3 afthe Business and Professions Coca)or 'FEMA.MIOER OR POLE INST. 19
MMERCIAL-
It.6 c oOC that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
x t+•tD�
Section 7031.5 byanyapplicam tons"ra itsubjtsiume applicant toucivilpcnattyof POWER DEVICES tn L ANT ❑FWD SERVICE
Zp, tmnrc than Eve hundred dollars(5500). f// IMPROVEMENT
Q C 1,as owner of the property,on my employees with wages as their sole compensation, SWIMMING POOL ELF. RI (
will do the work,and the nmmunu is not intended oroffemd for sale Edec 7EUw Hueinese ❑OTHER
R1 and Professions Cade:The Cmumaors License Law does not apply tee am owner ofUTLETS-SWITCHES RES
6 a^ pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided monsoon improvements am nut intended or offered for NEW RESIDENTIAL ELECT t Q FT.
sale.If,however the buildingor improvement issuld within one year ofeempledurt.theSQ.F.FLOORARHA S/SQ.IT.
owner-builder will have the burden of proving that M1e did not build Or improve for par- M
C 1,as owner of the propeny,am rom exclusively nuacting with licensed contractors TA,so of
construct Ne project(See 7044.Business and Professions Cale.,The Contmcmrs Li- Y
ase Law does not apply to an owner ofprepeny,who builds or improves nation,and QTY. PLUMBINGPERMI FEE -
who comtmen for such Projects with a conuaaooti)licensed pimmunt to the Contractor's
License Law, PERMIT ISSUANCE
❑I mat exempt under Sec. .B A P C fur thio Itasca
owner Date
ALTER-DRAIN&VENT-WATER(HAL A, O
WORnderPenalty
COMPENSATIOn DECLARATION BACK FLOW PROTECT.DEVICE
I he"by stria.n ism Cerin rale fCorwam of serf-m nefor d¢buations:
ti ❑or.as andwientfor m Studio.377 of the LabmCode far theIWmkrouCompen- DRAINS-Fl.00R.ROOHAREA,COND. STORIES TYPE CONSTRUCTION
murk,as provides for mi Ss issued,
3?00 of the Lahnr Cale,for the performance Of the 1 I s PQ I'/I` +I
wad for ty ad tilispenniin issued. - FIXTURES-PER TRAP V '�,i -
1 hove and will maintain Wodror Cmme of
Insurance,h required t i Section -
TlOO of the lahorCWgfar the performance mf the work for which this hermit is issue). GAS-F.A.SYSTEM-I INC.40UTLE1'S .00C.GROUP _ APN
My Work erq Cor�peys�iogJnSul'aIlS.c rand Policy number e G
Carrier. AL Polity N, Z A /r 21901 GAS-EA.SYSTEM OVER 4(EA) /rte
xr CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS[/INDUSTRL WASTE INTERCEPTOR N
COMPENSATION INSURANCE B DIVISIONFEES
(Thu section near not be completed lfthe permit is foto e,hundred dollars($IN))
GREASETRAP
ar less.) PLANCHECK I. C
I certify Natimhe perfmnner o as twncomesuiject it)peemitisiss Compa11 SEWER-SANITARY-STORM EA.200 FT.
nut employ any person in any manner sat az to beeame suhjecuo the Workers Compen- ENERGY �
zz scion Taws of California.Date WATER HEATER WNENT/ELEC It
Applicant GRADIN
ti NOTICE TO APPLICANT.IL after making this Cenifcate of Exemption,you should WATER SYSTEMODEATI NG -
abecome subjeeuo1Ib Workefs Compensation provisions of the labor Code.you muse SOILS FILE
Lk1 fonhwieh comply with such pravisionn onhis permit strait bedcemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ.PI'. PAID pate Receipt
V 0 I hereby affirm that there is o construction lending agency for the performance of
to work for which this permit is issued(Sec.3097,Civ.C.)
E-' Landry'.Name TOTAL:
O V
W Lender',Address TOTAL:
I certify that I have Ovalmi,application and stun that the about information iBUILDING FEE
s
V) correct.)agree tocomply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V 7 building construction,and hereby randomize representatives ofthis city to enter upon the SEISMIC FEE
.11
above-mentioned prepeny for inspection proposes. PERMIT ISSUANCE.
(We)agree to save,imlemoify end keep harmless Ne City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way uttme against said City ALTER OR ADD TO MECH.
I.consequence of the granting of this pernil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL.HESOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of Apphcant/Contmcmr .Dae FXHAUST HOOD DODUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicant Or future building occupant smrem handle haricubms material HEATING UNIT TIO 100,000 BTU) _
as defined by the Cupertino Municipal Cal,Chapter 9.12,and the Health and Safety - -
Code,Section 25532(,)7 HEATING UNIT(OVER 1 W,00so SITE)
❑Yes .4No VENTILATION PAN(SINGLE RESID) PAID
Data Re<ciptp
Will the applicant Or future building occupant use equipment or devices which BOILER-COMP OHP OR 100,0(10 BTU)
m -
erat hardos uair conturarmas as defined! the Bay Area Air Quality Managemedl TOTAL:
e Duto"? d`'� BOILER-COME(OVER 100,000 BTU)
❑Yes Fes,
I have read thew
laohm,maeruts acquirements under Chapter o95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forms Health&Safety Cede.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH.
.tanking c1ces..curently have,tenant,that it is my resgo sibilay mma fy the ascupant
of Wt ms hit man be met prionoissumece ofa Cenikcate of Qeupanc
Owner ora i Date TOTAL: ISSUED BY:
OFFICE ��