27179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLU - . - PERMIT NO. ^ ^
BUILDING DIVISION APPLICATION/PERMIT MBING-MECHANICAL, r
BUILDING PROJKI,T IDF.NTIF'ICATION 9
BUILDING ADDRESSG
: / SANITARY NO. APPLICATIONSUBMTALDATE
'Ale, ^/(�/ _ UNIT# LOT It
O ERSNAMIc ,r
r 3 PHONE: t v Cr13 NIC f CO ROLA
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HITF.CT INF NO: ADDRESS' /�v®— �•1' (� 11NTA PHONE: QTY. ELECTRIC PERMIT lJY /FEF. BUILDING PERMIT INFO
yyBLDG ELECT PL MECH
v-/ PERMITISSUANCEEl
LICENSED CONT ORS DECLARATIONAPPLIANCES-RESIDENTIAL
LOB DESCRIPTION
to IherebYnfimd ed pmvisions ofCheAter9(commencing with
�iJ 00 Section 9000)of Division 3 of the Business end 0 fessims Coda end my liceme is in PANELS
F-. full force and effecter. �F4
FZ tw Licrox Class Lick UPT0200AMPS �Jy� Pte✓/..�,�
y 6 y Date Connote 201-I"AMPS
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ c—,;O I undersmnd my plans shall be used us public rccoNs.
ce 2c W SIGNS ELECTRICAL
JJq'g J Licensed Professional '
W'U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I N p -.: _ ,r'
I hereby tiff that 1 am exempt from the Contractor's License law(or the n N
u131'-m following reason.(Section 1031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
X 01 which requires a Permit to construct,alter,improve,demolish,or repair my sructme f,1
Y prlortoits issuance,emici,mr.too plicantforsuch permit to flee sigmultaitement POWER DEVICES I -J 1 GIrCi'
O that he is licrnsed pursuant o the provisions of Ne Contractor's License Law(Chapter
a o�o0� 9(commencing with Section 7")of Division 3 ofthe Busincesand Profusims Cade) SWIMMMGPOOLELECTRIC VAL TION
yf_^y or that he is exempt therefrom and the basis for the integral exemption.Any violadoo of OIITLEfS-SWITCHPS-FIXTII
1=4Q Section 1031.5 by my applicant for a Permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500).C NEW RESIDENTIAL ELECTR 5 .PT.� ❑ I,uownerofNeproperty.ormyemplayeca wiNwaguu Ncirmiecompertsadon, _SQ.FT. TYPECONSTRUCTION
y will dothewon,Crude:
ewmurelsnm is Lice.
144,Business
and Pmfadolm Code:The Conhereon.License Law time or apply tom owner of
property whobuildamimpravu Nerean,and whodcesauch work himselforthroughhf, OCC GROUP RES.UNITS
ownemployces,prang or Improvement
can earrafdmplatio ,the owner,
however,the building or of proving
is hath ei i in one yeti our improve for the owner- TOTAL:
builder will have the burden of proving that he did not build m improve for purpose of
tile.).
❑ I,esownttoDhe Property,am exdusivelyconhecting with licevedmntmnonm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.TDW,Business and Professions Code:)The Connacmr'a PERMIT ISSUANCE
License Law does not apply to m ownernfpropeny who buids or improves thereon,and Y
whocomracts ressuch projects wit rkeentmmmEd licensed pursuamtothe Contommr's
Limns law. ALTER DMIN&VENT-WATER(EA) FEE SUMMARY
El 1 am exempt under Sea ,B&P C for this reuon BACK ROW PROTECT.DEVICE SANITARY Y N
Omar Dme RECEIPTN
WOR KMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOLTAX Y N
I hereby affirm that I have a certificate ofemsem to self iname,m e certificate of RECEIPT M
FIXTURES-PER TRAP
mote Cmnpcnss aorderridspora certified copy Hereof(Sec.JgIXl,Leb CJ which PARK FEE 1Y._N_
ere all cmpleyer's under Nis pemtif GAS-EA.SYSTEM.I INC.4 OUTLETS REC
Einit—
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
• ❑ Certified copy is hereby famished.
❑ Candied copy is filed with the city inspection division. GREASE4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section=ed not becmmplmed ifthepernit is for one hundred dollars($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orlea,) y
I certify that in the perfmmanceofthe work for which Nis permit is issued.Isbell l WATER HEATER WNENT/ELECTR
not employ my person in any manner so as to become subject to the Workers' PAID
Z Compemmionlawsof Caliromis. Dem WATER SYSTEWREATING Date Receipt
Applicant
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
F-e Zi becomembiset 1.the Worker's Comparisons.provisions of e Labor Code,you most
>` forthwith comply with such provisions or Nis Permit shell be darned revoked. BUILDING FEE
6Wi A CONSTRUCTION LENDING AGENCY SEISMIC ME
z 1 hereby affirm Nm Nem is a cons mec,ion lending agency for Ne performance of TOTAL: ELECTRIC ME
the work for which this permit is issued(Sec.W,Civ,CJ
I2-tLende'.Name PLUMBING ME
F Lender's Address QTY. MECHANICAL PERMIT FEE
WI certify that I have read this application and sure that the above information is MECHANICAL FEE
a comma.Iagrecmcomplywithdl.kyand...oY Eopences andmam laws rcI.dngm PERMIT ISSUANCE
_ buildingcommction.and hereby authorise represenulivesofthis city to enter upon the CONSTRUCTION TAX
U 'z above-mrmioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kmp harmless Ne City of Cupentm against
Iiabilitics,judgmems,cons mtdexpeueswhichmay in my way accrueegeimt said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,0(10 CFM)
Signiame of Applicant/Contractor Date EXHAUST HOOD(W/UUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt If
Will the applicant or futurefuturebuildinging building orcmcupa p erote or hurdle Health a material HEATING UNIT(OVER 100,000 BTU) TOTA
C defined by rhe Cupertino Manicipel Cad<,Chapter 9.12,andthe Health and Safety
Code.Section 25532(a)') VENTILATION FAN(SINGLE RESID) T
❑Yes ❑Na
ISSUANCE DATE
Will Neapplicmtorf Ramlodildingmr,cam use,iiipmemmdevlceswhichemitBOILER-COMP OFT OR 100,000 BTU) ``11 10 199
4
4sooue air contaminants as defined by the Day Area Air Quality Management 11
BOILER-COMP(OVER 1,000 BTU) �Otl
1Wct1
❑Yes 0N NEWRESIDENTIALMECH. SQ.FT, rllY Ur a,urr.t"INQ
I have rend the hamadom matcrids requrtemenrs under Chapter 6.95 of the V
California Health&Safety Code.Sections 25505,25533 and 25534. I understand that
if the building does not currently have a tenant,that it is my responsibility to unify Ne
occupant ofNe requirements which must be met prior to issuance of a Certificate of
Occupancy. T■.A• �t
Owneraraulhmi,adagent Dam TOTAL: ISSUED BWJ J
OFFICE