2594 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
LOWNE
9F CUPERTINO BUILDING-E.E 1 AL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL g] �
BUILDING DIVISION /� BUILDING PROJECT IDEN'r1F'ICSrR)N L'FJ 944
BUILDINGN:y DJESS; ` ` + .�-/ �UNITk LOT SANITARY NO. APPLICATION SI DATE
`/.VTC 'L/./vJ14
SNAME: ;1 NE: CONTR CTOR'I NAME: LIC NO:
z Z P7a NIC CONTROLp
ARCHITECT/ENGINEER: LIC NO: AW E/. /� J. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PER IT FEE
B MEC
co•-',+1 �IV►Q/+ 37/—fy-fa PERMH'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION gPPL1ANCES-RESIDENTIAL I�pN
py.Z Ihereby affirm that l an limenxdunderprovisions of CTapIm9(commencing with r-
[ OO Section 1000)of Division 3 of Ne Business and Professions Code,and my license is in PANELS
F� � fall arm erreet.
Liccmv Qg
License Class Lic.p UP T0200 AMPS
Ori a Date Common 201-IOW AMPS vvv rrr non
h Z 1 merriment my Plan.Rhelllbc used as PubTECTS lic DECLARATION
TV II F1' Ary-E 11 E/SQ.FT.
7.O,x- OVER 1000 AMPS U OVrI L..r' �I
PIS❑
F y C SIGNS ELECTRICAL
sg
Licensed Pm(esaionel
0.Owl, OWNER-BUILDER D[CLARATION SPECIAL CIRCUIT/M1SC, 02> p (� �J�
W3g I hereby n.(Se that I em exempt from the Contractor's License 4rw for the _`
following inguina a ermt to common.
.sineasand
pe Professionsdemolish,
h,or Code: city stmemcounty TEMP.METER OR POLE INST. TE w
[_��; which requires Permit re cores the applicant
shcclmporsuch ennit t,or repair anyswmure
poor mils issuance,also requires the apPlicam for such permiuo file aligned smmmmt POWER DEVICES
)yCOp that he is licensed pursnanl n)the provisions of the Contractors License Law(Chapter
'a•,ao 9(commencing with Section Division 3 of the Bminessand I'mmodims Code) SWIMMING POOL ELECTRIC VALU
,_,, or he is exempt herefrom and the basis for alleged exemption.Any violmionof
h Z Q Section 7031.5 by any applicant Be a permit subjects the applicant a civil perely of OUTLETS-SWITCHES-FIXTURE.$ /" �]OOD
mol more than five hundred dolle,S5W). [
wpm ❑ I.axnwnerofthe t ye p Y B len=ion, NEW RESIDENTIAL ELECTR Fi.
proper y.onn m to eeswith wa es astheirsolecom —SQ. STORIES TYPE CONSTRUCTION
x322 will do the work,and the structure is not intendedoreffcred forsale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thernm,and whodmes such work himself or through his
own employees,provided thairuch improvements arc notimendedoroffered reside.If,
OCC GROUP EAIN
however,the buildingor improvement is sold wiNinone yemofcompletion,theowner-
builderwillhave the burden ofpmvingthat he did not build or improve for purpose of
sale.).
❑ I,as,ownerethe property,amexclusivelycnmecing with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE
construct the project(Sec.7044,Business and Professions Cade:)The Comments
Licence Luwdaea mol apply to an ownerofpropeny whobuilJsorimprovesthereonand PERMIT ISSUANCE
whocommen for such projects with a comeactogs)licensed pursuant od¢Cenuaamr's pLTLR-DRAIN&VENT-WATER EA)License Law. FEE SUMMARY
❑ 1 and exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UI'glDh FEES
SANITARY Y_N
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RF,CEI"#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ en'Coxnsai lhatlhuveacenifcmeofcon therof(S sure,orattmrmuimof FIXTURES-PER TRAP RECEIPTk
Workers'Compenmtinn lnsumnce oracenified copythereof(Sac.3800,LabCJ which PARKIEE YcoveN
rs all employee's under this pmaii. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPT'N
Policy If BUILDING DIVISION FEES
Com ert GAS-EA.SYSTEM-OVER 4 GA)❑ Cenifcd ropy is hereby fumisheJ. PLANCHECK FEE
❑ Cenifed copy is filed with the city inspection division. QREASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP SOILS PEE:
COMPENSATION INSURANCE
(This section need nut be completed iflle proton is nature handred dullms(EIW) SEWER-SANITARY-STORM EA.200M.
or less) ENERGY FEE
I cenify,loo inthe performance ofthe work for which this permit is issued.)she] WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Z
Como a
ptiminearof Celifamia. Dam WATER SYSTENVI'REATING
Applicant Date Receiptp
Q
z 0 NOTICE FO APPLICANT:IL after making this Ccnlfcme of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FI'. TOTAL
f" Cl!) become subject to the Workers Compensation provisions ofthe Labor Code,you must
7 forthwith comply with such Provisions or this pumit shall be deemed revoked. BUILDING FEE si�
y Q CONSTRUCTION LENDING AGENCY
SEISMIC FEE
z I hereby of firm Nut them is a construction lending agency for the perfmm em of
V O the work for which'hislwnmit isissucd lSec.3WI,Civ.CJ T ELECTRIC FEF,
Lenders Name
UU. Lenders Address QTY. MECHANICAL PERMIT FEE PI.UMBINGFEF.
1 certify that 1 have read this application and late that the above information is
F4 correct,l agree to comply with all city and county ordinances and state laws relatingto PGRMI'T ISSUANCE MECHANICAL ME
building construction.and hereby announce mpresrnmtives ofthiscity to enterupon the
U above-mentioned prnpery for inspection purposes. ALTER OR ADD Tn M PC 11. CONS'IRUCIONTA%
(We)a c to save,indemnify and keep Formless the City of Cupeninu against
liabilities ' d ents,cole and n swhich may in any way accrue against said City AIR HANDLING UNIT(TO I0,00d CFM)
trine uc •of rhe grans rhissperre t.
AIR HANDLING UNIT(OVER I0,0X1 CFM) �w
s
SigiMium of-AppIltamiCommeor Da EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date RereiplK
Will the applicam or futurt building occupant stem or handle h one dons mmeriul
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hcalth and Safely HEATING UNIT(OVER I WOOD BTU) TOTAL:
Code,Section 25532(u))
❑Yev EI No VENTILATION FAN(SINGLE RFSID)
BOILER-COMP ISSUANCE DATE
Will air
aco communities
ties as building by the
nBay Area Air Qualoy Manes agementchemit (3HP OR 1 W,f100 BTU) y�
�urarJ,? air contaminants ns JcEred by the Bay Arca Air Quality Management BOILER 100,11(10 BTU) A
)istrin'! y�
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the havnMous moleriuls requirements under Chuper 6.95 of the 4� ��
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that V
it Ibc building dues not cumen0y have a¢rant,thm it is my msponsibiliry m notify the
re"Faln of the orpoirements which must be met prior to issuance of a Cenificam of r Lu
Owner or autM1omed egrnt Date \y—�j /�rw/�jP/f//y/`1,
A : ISSUED 9Y:
OFFICE
or . Couper,41i,iD
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