28011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO nlm:oA7:-EI;ECTRICA 1 PERMrr NO, 0
APPLICATION/PERMIT PLUMBING'MECHANICAL.
RUILUING DIVISION BUILDING PROJECT IDEN'r[FICA'rION
11
BUILDING
GAAI�IDRR)1i5S: SANITARYNO. APPLICATION SUBBMMI!MAL DAM,
V ` UNI'1'N hO'I'N /D —S
OWNERS NAME: PIIONI3: CONTRACTORSNAME: LIC NO: /
_ �/� 1nnrH
ao NPC CONIRol.is
• ARC]HTF,CT/ENGINEER: OC NO: ADU05 YCi6Ij •lam
CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB ESCRIPI'TON
pyrz I hereby affirm that l am licenW underprovisions of Chapir9(cmnmancing with
FOO_ Section 9000)of Division 3 of the Business and Pmfc....as Coi,undmyliccnxisin PANELS �4'k` Ia,,," e/T
c': I-� full force unit cff yyyy////��!!
EzwUj i.iccnsc Clas_ Lic.M �� UP T02W AMPS C"CQJ„1 C�
mQy Date Cnanal., 201-1000 AMPS D�� 'N
ZFONz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT,FLOOR AREA $/SQ.ET.
OZ—a Tumderawodmyplana ahall be used republic records.
SIGNS ELECTRICAL
Lnerscd Professional
S:ww< OWNER-BUILDER DECLARATION SPECIAL CIRCUR'/MISC.
XO W, 1 hereby afGvn that I am exempt from the Contractor's License Law Rome
mj Oy following ....to(Sation?031.5,Business end Pfofn,mar,Codc:Any city ore ounty TEMP.METER OR PULL[NST.
which requires a permit t.construct,aper,improve,demolish,or repair any mmuctum
5yJ-� prior to its inuance,also requires the applicant for such permit to File aaigned,Otament POWER DEVICES
ce<O that he is licensed pursuant m the provisions of the Con sass's License Law(Chapter
o.a W q(cnmmencin th Sation'1000).f Division 3 clohe Business and Pmfiami...Cede SWIMMING POOL ELECTRIC
XoE` R`vt ) VALUATION
y_,e or Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURES 0�
Er,Q Section?031.5 by any applicantforape.to subjecime applicant no a civil Penury of /`�O
not more than five hundred Jollure(1500). NEW RESIDFNIIALELECTR S Fr. ✓
1F_o ❑ I..a.wnerofthepropery,nrmycmployew with wagcaasthei...lecompevamm, Q' STORIES TYPE CONSTRUCT ION
yjm will do the work,=it the almctum is not intended or offered for safe(Sec.7044,Business I
and Professions Code:The Contractor's License Law docs not apply to an owner of (/
proper who builds or improves thereon,unit who does each work himselfor through his OCC.GROUP HES.UtJT'S
ownemployces,provided that such improvements arenot intended or offered fireside.If,
however,the building or improvement is sold within one year of completion,theowner- TOTAL:
builder will have the burden of proving that he did ant build or improve for purpose of
solea
❑ Las owner ofthe property,amexclusively contracting with licensed communion'. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
onsuuct the project(Sec.70J4,Business and Professions C.de:)The Contractors
License Law thatraapply to roo—mar.1',xveny whobands.r improvm thereon,and PERMIT ISSUANCE
who contracts farsuch projects with acontracm s)licensed punusnt to the Convectors
License Law. ALTER-DRAIN Ar VENT-WATER IFA) FEE SUMMARY
❑ Tam exempt under Sec. ,B A PC for this mason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY T N
Owner Data DRAINS-FLOORROOT.AREA.COND. RF,CEIPrit
.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihertbyaffirmthat[haveattnificateofconaentioself-insure,macenificateof Fl%TURFS-PER TRAP RECEIPT
Wmkeri C.mpertutinn lnaerentt on cmifirdcopy Nertof(See.lg00.lab C.)whiah MARK FEE T N
coven allcmploYqq�,,gS 1 t. a� RECEIP #
Policy N I�k�.� el O—V GAS-EA.SYSTE -I INC.INC.40UTLErS BUILDING DIVISION FEES
C.mpany� sYs g1. NC1I GAS-EA.SYSTEM-OVER4EA
❑ Gasified cop hereby famished. ( ) PLANCHECK FEE
❑ Certifiedcopy is filed with the city inspection division, GREASEpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSG 5PAIRT
RAP SOILS FEE
COMPENSATION INSURANCE
(Phis satins nadnot bec.mpleted if Ne permit is(.Tone hundtcs1dollars(SI110) EWER-.ANITARY-STORM FA.2WF1'. ENERGY FEE
or las.)
I certify that in the paformantt of the work fm which this permit is ivuW.I shall WATER TER W/VEpT/ELECTR
urn employ any person in any manner m as an become subject m the Work PAID
Compensation Liws.f Cadifomia. Data WATERS TEMTRRATING Date RaeiplN
O z Applicant
z O NOTICE TO APPLICANT If.after making this Cmificere of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' ^ become subject o the Worker's Compcnvtion provisions of the Labor Code.You must
� > forthwith mmply with such provisions or this permit shall be deerned reeked. BUILDING IEE
0. Q CONSTRUCTION LENDING SEISMIC FEE
I hereby affirm that them a is cons4ti.n lending agency for i par a of
U C) the work for which this permit is issu (Sec.3090,Civ.CJ TOTAL ELECTRIC FEE
Ienokr s Nance PLUMBING FEE
0 F Leader's Address MECHANICAL PERMIT FEE
U T artily Nat I have reed chi epplirnitm e n fo nion is
F a corms. lagrtc to mmplY with all icy and coed a dsm le tum". PERMIT ISSUANCE MECHANICAL IEE
building construction,end hereby thorim rtpm esofthiacityt enteruponthe
U z above-memumad property for imps tion pury wes ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnif and kecp I s Ne City of Cu,smour against/
liabilhies,judgmenu,insistent axperrr��P++eees which may meny weyucmengainst aid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of tht'{permit /
\` AI0.HANDLING UNIT(OVER I0,000 CFM)
Signature of AWlicant/Comracmr \ / Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT(TO HXLXs3 BTU) Data Receipt N
Will the applicant or future building occupant most or handle haaardon material HEATING UNIT OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code;ChaHand
pter 9:12,and the ealth Safety
Cade Section 25532(4)?
❑Yes ❑No VFN ILAT[ON FAN(SINGLE,RESID)
BOILER-COMP(3HP OR 100000 BIL) ISSUANCE DA'1'17
Will the epplica u mfomrc buildinm
goupant usecquipm .
att ordsvices which emit ._
hattr lmis air mmaminanu as defined by the Bay Area Air Quality Management
BOILER-COMP(OVER I W,Ofq BTU)
District 0
❑Yo ❑No NEW RESIDENTIAL MECH. SQ.f4. Cr �
1 have read the havtdous materials Tcquiremcnu under Chapter 695 of the a ](1n
Calif rmi a Health ik Safety Code,Section 25505,25533 and 25534.1 undmuM that
if the building does not currently have a tenant that it is my responsibilitym notify the L r /
mornpam of the rcquiremenu which must be,met prig to issuance of a Certificate fy r.v�
Occupancy.y�l� /=/// /o—��!
Owrterm/T/N—(onutl agent `(( aJ
Data TOTAL: ISSUED BY:
OFFICE