28190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELKC`I HICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING.-MECHANICAL / x 1 Q O
BUILDINOPROJECT IDENTIFICATION L V y V
RUILDINGADDRRESSSS /�� SANITARY NO. APPLICATION SUBMITTAL DATE
0 // ! UNITp LOTp �raa�gs
OWNF PHONE: CONTR CTOR:S NA LIC NO:
�.. N/C CONTROL
p
ARCHITF.CT/ENGI :E@ LIC NO: ADD S: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
e—g �� //1/1 /t ftLOG LLELT PLUMB MECH
L— G;J(r.(/�'D PERMIT ISSUANCE El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DGSCRII9'ION
Gt'Z I hereby affirm that l am licensed author provisions cf Chapmr9(contmrncing with
X00 Sonkm 10(Ilpof Divisi�n Sof the BusinewInd Pmfwsiom Code,and my[it..is in PANELS
UE full force and effect. v
¢Z LRcnac Class Lic.p UPTO200AMPS
yQa Date Compactor 201-IOW AMPS
z Orn Z� ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.Fi000.AREA S/SQ.FT.
Oz—a l understand my plans shall IN used as public records.
H ' SIGNS ELECTRICAL
....ff Licensed Professional
KOyUKms¢ OWNER-BUILDER UFheContTON SPECIAL CIRCUIT/MING.
1 hereby xffinn mm 1 am exempt from @t Contractor's License law for she
t E:0. following masnn.(Section 7031.5.Business and Professions Code:Any city M County TEMP.METER OR POLE INST.
���n which requires apemtit to connote,alm6 impnwe.demolish.mm,mr any moneture
WT7 prion,,its issuance,also....irts the applicant forsuch Penniuo File a signedsuemens POWER DEVICES
y)IYpOC she he is licensed pursuant to provisions of the Contractor License Law(Chapter SWIMMING POOL ELECTRIC
mxm�LL 9(commencing with Section 2000)of Division 3 ofine Business and Professions Code) VALUATION
W_m or that he is excmpthercfrom andshe basis for the alleged exemption.Any violationof
zG Section 7031.5 byanyapplicam forapeman subjects the applicant ton civil penalty.( OUTLETS-SWITCHES-FIXTURES gIOQ 10 V
z@@ nor..at than live hundred dollars(5500). NEWRFSIDENI'IALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
tY
Elpr
t- I.asowneroftheopony,ormyemployeeswithwagesustheirxlecomp madon,
m
y322 will do he work,and the structure isnmin¢nded moffned forsale(Sec.00l4,Business
and Par essi.m Cde:The Cnntraa.r's Li,emc Law does an,apply m Int r of
progeny wM1obuildsnrimpmaesthercon,nndwhodoes tach warkhimxlfo meehis OCC.GROUP RFS.UNITS
ownempbytts,proviJed Nut such improvemcnta ane nos imm�Jduroffe dforsalc. f,
however,the building or improvement is sold within one yearofc.mpl oartheowne TOTAL:
builder will have the burden of proving that he did not build or imp ef.rpmposeo
sale.).
❑ 1. sownerofthepmpeny,amexclusivelycontracsingwi nsedcn:nmemrst. 1'Y. PLUMBING PERMIT EE F100D-LONG qPN
construct the project(Sec.'/044,Business and Pmfessi ale)The Contractor's
License Lawdocanoupplyso an.wnerofpmpcnywho dsorimprovesthereon,und PERMIT ISSUANCE
whocomordsforsuch pmjemswdhacmmamor(s)lie xdpursmtnmdecrammomle ALTER-DRAIN&VENT- E
WATER
License law. ('A) hEE SI1MMARY
❑ 1 am exempt under Sec. .B&P C for this occomm BACK FLOW PROTECT.DEVICE E ES
SANITA N
Owner Date r RECEIPT p
WORKMAN CO SATION DECLARATIO /' ) t RAINS-FLOOR,ROOF,AREA,GONWBUILDING
Y_N
❑ Ihcreby affimtthesl have niticme of consennn sed-imus, r cat ie ofRECENT0
XTURES-PERTRAP
Worken'Compensationlm ce oraceniRd copy creat ec. C.)w'hich E YN_
covers all emp[oyce.unde hispmniI. •'y OILS-EA.SYSTEM-1 INC.40UTfETRECF.IPTM
PoIICypB ILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) IECK
❑ Cenifiedcopy is hertby bmishcd. / /
❑ Cenified copy is filed wi the city inspection div I GRFASFnNDUSTRL WASTE INIERCG ME
CERTIFICAT[i EE%GMI'f10N FI20 OItKERS' GREASE TRAPE
COM NSATION INSURANCO 2
(This section need not he Co pletedifthe Forninsforanehundre ollan(EIW7 SEWER-SANITARY-STORM HA.2 FEE �.
ar less.)
i cenifythmintheperfotman ofthe work for which thispc it is issued,i shall WATER I[EATER WNENT/RLECTR
nut employ any pe,mc in any m. n as m become s lea m the Workers'
Compensation Laws of C.1ifomin toe. WATER SYSI'EM11'RIiAI INC, Dat Reccid It
z ^z Applicant
NOTICE TO APPLICANT:IL of Cana Eng this Cenifi to of F.xempti.n,you should NEW RFSIDENI'IAI.PCMB. TOTAL:
r+ y become subject m the Workels Cumpem tion provis' of the Izbor Cade,yen must
�h 7 fonhwith Comply with such provisions or is PC shell be deemed revoked. NG FEE
aQ CONSTRUCfIONL ING AGENCY SEISMIC FEF. IS
V Z 1 hereby affirm that there is a construction lending agency forhe an
Tperfnrmcc of
0ework I.,which this pmarn is issued(SCC.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
u' P Under',Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
O U I cmdfy that I Love teal this appl lcalmn and state mut the.have information is MECHANICAL FEE
Conect.l."Colorma ly wilhalleityeale - dstmelawspeladngm PERMIT ISSUANCE
1-' building Conswction.and hereby audt reprevenutivesaftH lytornteruponthe CONSTRUCTION TAX
U z above-nmminned pro for insp ion Purpscs. ALTER OR ADD TD MF.CH.
tti (We).gree m save,in omni and keep harmless the ' of Cupraden against
Iiabilisies,judgmenn, dexpe swhichmaym aymoome against said City AIR HANDLING UNIT(TO IO,OIIIICFM)
in segae n M .Amit.
AIR HANDLING UNIT(OVER 10,000 CFM)
signewrco pplicun for D. EXI IAUST HOOD OVIDUCT - PAID
,04'AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.008 BTU) Date Raeiptp
Will the applicant or future building occupant store or handle hazardous ma mold TOTAL'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Cdc,Session 25532(a)P VENTILATION PAN(SINGLE RESID)
ISS
BOILER-COMP(311P OR 1013.000C3 ,000 BTU) tJAjyCE Yes 11Nn
AT
\
Will thtapplicanlnrfmurchuildingacupantuuequipmenmrdevices which<mis B 6th
tramNous air contaminants as defined by fhe,Bny Area At,Quality Management BOILER-COMP(OVER I0II.000 BTU)
Distriel'f ,qhs p8 �
❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FT. y 1WOQ
I have real the hazardous materials requirements under Chapter 6.95 of the v
California Health&Safety Core,Sections 25505,25533 and 25534.1 understand that Uro yr�N
if the building Jens nut currently have a mount,that it is my responsibil lty In notify the
occupant of the requirements which must be met poor to issuance of a Certifteme of
Occupancy.
Owner or amhorimd agcm Dam TOTAL: ISSUED BY:
OFFICE