28050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELERI AL PERMIT NO. 0 O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS
/�, �(� SANITARY NO. APPLICATION SUBMITTAL DA'C
f 0L ��GJ e r/0 UNIT# LO I'll
' PHONE: I ❑NIC T� r�uERM �� CNCO
IECTAIJGINEER: LIC �
NO:
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
APPLITCES-RES Ry I
LIC+ SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB UESCRIPHON /L]L
poc Thereby affDiihml 3 ofthe Business
add rofiesofns Code 9nd mmeneingwhM1
�n00 Scnion]1N10)of Division3of the Business and Professions Code.and my licenxe is in ppNEf,g
AUG full force and effort. .k
ow
FZW Licen,c Class Lic.# UPT02MAMPS T� l
w?y Danm
e Contractor 201-1000 AMPS '
Z�NZ ARCHITECTS DECLARATION OVER INEE AMPS SQ.FI'.FLOOR AREA E/SQ,FT.
O Z " I understand my plana shall bo used az public recoNs.
Fm SIGNS ELECTRICAL
Licensed Prorcvsional
�CL'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oa. I hereby of irm Ihat 1 oro cxcmp from thuCom csror's License Law for the
tL3ay following reason.(Section 1.31.5,Business alN Profesxi Cale:Any city or county TEMP.MEIER OR POLE INST.
which requires a permit to ammm�.ober unprove,demo ish,or repair any strucwrc
��}� prior In its issuance,elm requires N�applicant for such pe uo flc aaigned summtnt POWER DEVICES
W p<00 that he is littngcd pursuanu0thypmvisiona of lM1e Commgor'a License Law(Chapter
a P'e�i' 9lcammcncing with Semioy97 q)of Division3orthe Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
[-K^< onhat he is exempt thereflmn wdthe bazis for Ne all<gcd exemption.Any violmionof OUTLETS-SWITCHES-FIXTURES I A ��
7=¢ Semitn]03LS ppliwm(orapertnit aubjectn the\Plicam toacivil pcnnity of `l..)
not mom Than f hundred dollars(5500).
K F-o ❑ Laso fthcprnpeny,ormyemployees withwagcsaztM1c solccompcnsatioq N'GW RFSIDIiNTIAI.ELCCIR —SQ.17, STORIES TYPE;CONSTRUCTIOD
i3=° willJo rk,and lhuwcmmis not intended ornffcred foraale( .]tN4,Business
end Profesamns Code:The Command Littnze Lew does not app men owncf of
prnpeny��``''ho builds nrimpmves 0erenn,anJ whoJree hwork himw onhroughhis
mpldyas.providrdthatauch improv(men��++pp�� tengeJ aoffc forsele.If, OCC.GROUP RES.UNITS
however,thebuilding nrimpnrvemem is.c ry{wi7pb^m (ofcnmpla' na owner- L
boilJer will Have the burden of p v th-Jy)e d y of build crimson for p\ of
❑ Lazownemfth rope y.a i- '.vclycontraning with li nscd conuacmnm QTY. PLUMBING PERMIT FCC F100D ZONE qpN
cons Of the b cat ce. rimes,and Professions C e:)The Contractor's
Lace nsel.nwda ply unownc1.f1la1nyv,hob.i1le rintpmveslhereon,and PERMfIISSUANCE
who nut,I suaA m ithacmd svr(s)rccm,aE'nnantmthe Cnnuanots ALTER-DRAIN&VENT-
LicenseLaw. / WATER(EA FEE SUMM RY
❑ 1 am exc. I under, ,B&P C for this tersest 111.11 :ES
\ / RACK II-OW PROTECT.DEVICE
Owner / SANITARY Y N
Dale DRAIN -FLOOR. F,AREA,GOND. ITT#
\ ORKMAN COMPENSATION of ONDECLARgTION SCHOOLTAX N
❑ Ihemhyaffr thmJhaveacenifcat yf consemmself-imure,mucertifcam of Fl RES-PER TAA ECEIPT#
WorkM Compcnxti Insurancemaeerdfetl copy thercof(Sec.3100,Lab CJ which PARK FliF, Y N_
covers all employee's on rlhispertniL/
Policy# / AS-EA.SYE'IEM-I INC. OUTLETS RECEIPT
Company
R I ING DIVISION FEES
th / GAS-EA.SYSTCM-OVER4 A)
ElCmifitJ copy is hereby rumished. PLA, F,
❑ Certified copy is filed wild Weeny inspection division. GREASB/INDUSTRL WASTE I ;RCEPTOR GR I G
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE �r
COMPENSATION INSURANCE
(This section need not be completed ifthe permit isfwone hundred doll (EFW) SEW ANITARY S EA.2 IT. ENERGY
or less.)
I cmify that in the performmrcmf0e work for which this .it is is, d.1, all TER HEA pENT/ELECTR
of employ any person in any manner so az m become subject to the eat, PAID
z Compensation Laws of Cnlifnaia. Doc WATF. I/N fRIiATING Dae Reeeiptp
Applicant
z 2 NOTICE TO APPLICANT:If.after making this Cenificae of Exemption,your old NEW RESIDENTIAL PLM SQ.Fr. TOTAL:
ry bccnnm subjecuolhe Worker's Compensation provisions of the labor Code,you use
Ex > forthwith comply with such Provisions or this permit shall be deemed revoked. ILDING FEE
0. Q CONSTRUCTION LENDING AGENCY F-ISMIC IEE
z Ihereby anion that here is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,CI,C.) EC RIC FEF.
Leader's Name
00 U Lander',AJdrt„ QT MECHANICAL PERMIT FEE LAMBING FEE
1 ttof fy that I have rtad this application and nm ethat the above inf rreammn is
0. correct.lagreemcomply with all city and county ordinances and num laws relmingm PERMIT ISSUANCE - MEC NICALFEE
F-' building commation,and hereby aulhorice apraeoativesofthis city to enter upon the
V Z above-mentioned preycny,for impectinn purposes. ALT ER OR ADD TO MECH. CONST ICTIONTAX
(We)agree Io save.Indemnify and keep hmmless the City of Cupertino against
liabilities,tel te,conx Jtxpenatsw "chmayianywayacerutagainnsaidCity AIR HANDLING UNIT(TO 10,000 CFM)
arO I q oflhc", gnRhls it.
EAxAIR HANDLING UNIT(OVER IO,BQT CFM)
Signature of APplican � I Do EXHAUST HOOD(W/DUCry
PAID
ZA RUOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date R. p
Will the applicant or furore building cecupant scare or herWlc haasMoua mamrisl
asdef tied by i he Cupcnino Municipal Code,Chapicr 9.12,and the Health and Safety HEATING UND(OVER 100.000 BTU) pL:
Code.Section25532nd?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP CTIP OR 100.1100 BTU) ISSUANCE TE
m a
Will the applicwmrfmurc buildingcecupanmscegaipmentordevittswhich emit /�.E1
haranloh commina
nrn,as dclined by the Bay Area At,Quality Management BOILER REJ."BTU) PW P
'District? nn..
❑Ye, ❑No NEW RESIDENTIAL MFCIL SQ.IT.
I have read the hmadous micen.ts regoire rams under Chapter 6.95 of the •'IM 0
California Health&Safety Code,Sections 25505.25533 and 25534. lundemandthat `.!' 1995
if the building does not currently have a tenant,that it is my responsibility to notify the I-V
aeinnuo of the requirement,which nbe
un mel prior to issuance of a Ctrtificam of h IeUf+ U
Occupancy. ,I r N
Owner or adho sed agent Dare TO
ISSUED BY:
OFFICE