28166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO H ILDING-BLECI'RICAL PERMITNO.
APPLICATION/PERMIT PLUMIIING-MECHANICAL. 28166
BUILDING DIVISION BUILDING.PROJECT LDF,NTIFICAT'ION
BUILDING AUORfSS: � SANITARY NO. APPLICATION SUBMITTAL DATE
UNI'1'N LOT#
O AAfk� NI:: 1�.� CONTRAC�R'S�t[AM LIC NO:
C '
H f L IN J'L NIC ONOLp
ARCIII'I'ECT/E.. UINEHR; LIC NO: DRP.SS: t ❑
CONTACT: PHONE:
QTY. ELECTRIC PIiRA1IT FEE BUILDING PGRMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE F-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DFS Pfl N
E y00 1hereby 7ffl0) fDi ihml umlida,Bacunderpmvioiansof Chaper9(tmmecense with
�i106 SRIi0a9(glit if Division3ol the Business end Prolessinns Cale,end my license is in PANELS ' `
y�Bl���";; fallLicense
nse Cl deffea. - w
FZW hittnx Class Lie.If UP TO 2(t,AM15
rn Q y
Data Cnmector 201-1000 AMPS
ZOy4 ARCHITECTS DECLARATION OVER IWBAMPS SQ.PT.FLOOR AREA S/SQ.IT.
OZ,❑ I andenlnnd my plans shall be used as public records.
F L F; SIGNS ELECTRICAL
a � Licari Professional
�Jax OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W 3LLy following 1 batch,afro tbal 1 um exempt frothe Commence.License Law for the
C�� wing mamn.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POL1'.
E INS'; which empires is permiva consumer.shit,improve,demolish,or taped,any structure
Y:� prior to its issuance,also rcquirestbeapplimnt for such permitm fa
lesignad settlementPOWER DEVICES
fJf�gOz the he is l erased pursuant to the provisions of[lie Cmnm
tctor'x License Law(Chapter SWIMMING POOL.ELECTRIC
S tyoLL 9(commencing with Section 7")ofDivision J ofthe Business unit Professions Code) VALUATION
QM, or that he is exempt therefrom and the basis for Ore alleged exemption.Any violation of OUTLETS-SWITCHES-PI%TUREg
Za Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than Ove hundred dollars(SS)(B.
ce nt ❑ Lasownerel theptopmy.manyempleyeeswith wages as tlichadecommosall.m. NIEW RIESIOF:N'1'IAL h'LF.CTR S Q.FT.
STORIES TYPE CONSTRUCTION
ywill do the work,and the swcture is nm inendedorofleted forsile(Sse.9614,Business
and professions Code:The Contractor's License Law does not apply to an owner of
proper who buildscr improvesthereon,and whodoessuch work himselforthrough his
nnployecx,pmvidultbmxudtintpnivemennarcnntintendedor of feted(made.If,
OCC GROUP RES.UNITS
howeversthe built ingor improvement is sold wiNin oneyearofcompletion,the owner- TOTAL:
huilder will have the burden of proving the he did not build or improve far pugtoie of
le.).
12I,asownerofthepraperiy,amexclusivelycono-uctingwilhlicen.vedcmmritanrst0 QfY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7014,Business and professions Co e:)The Contractor's
I.icense Luwdmsnotapplytoanownerofpropenywhobuildsofimpmvesihereon,and PERMIT ISSUANCE
whocommets forauch projects with a contractors)licensed pttemnt to the Comractoes pCUiR-DRAIN&VEMf-WATER fA
License Luw. BE ) FEE SUMMARY
❑ I am exempt under Scc. ,B&P C for This ma n BACK FLOW PROTECT.DEVICE OUTSIDE PEES
SANITARY YN
Owner - - Date - RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARA'T'ION - SCHOOL TAX YN
❑ Iheehyaffion0etltionam or a camped
copytheoxl6ieue,sn Lah C.)which
RIECIEIPT#
Wmkeri Com FI%TI1RL5-PER TRAP
pensation lnmmnaorscevifiul copy thereof(Sce.7Bo0,Lab Cd which PARK ItiE YN
4 Pawn ell empinyceeundonhis pcmtilGAS-IEABUILDING DIVISION
SYSTEM-1 INC.4 OUTLETS RHVISI #
Policy p ON FEIS
Company GAS-IA.SYSTIEM-OVER 4 EA) PLANCHECK FETE
❑ Certi0ed,opyisherebyfumished.
❑ Cernfial copy is filed with the city inspectinndivisioo. GRFASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CIER9'IFICA-1 E OF EXEMPTION FROM WORKERS' GRE.ASETRAP SOILS FEE
COMPHNSATION INSURANCE
(This section most not be completed ifthepmenii is for one hundred dollars(6100) SEWER-SANITARY-STORM EA.2001rT. ENERGY FEE
or Ins..)
I cevifythat active Perfnrotancepfthe work far which this permit is issued,i shall W 4iI.ECIR
not employ any person in any manner an as a become subject to the Workers PAID
Compsminionlawsof Califomia. Dme WA'I'ER SYSTEM[EREA'1'I Dae Receipt#
Z Applicant
O0 NOTICE TO APPLICANT;If. frar making this Card fears of Exemption,you should N LPLMEL SQ.FEE TOTAL:
Co bce.m9xbjact 1.the Worker's Compensation provisions of the Labor Cade,you must
> forthwith comply with such Pmvisinns or permit a hall be deemed revoked. BUILDING ME
LQ la CONSTRUCT ION LENDING AGENCY SEISMIC FEE
Z I herebyri Boo that there is u construction lending agency for the perfonmmceof
the work for which this permit is issued(Sm.7097.Civ.C.) 'TOTAL ELECTRIC FEE
Lenders Name
OF Lenders Address QTY. MECIIANICAL PERMIT FEE PLUMBING IME
L) 1 cavity that 1 have read this application and state that the above information is -
s�' a emem.Iutam to comply with all city and enumy ordinances add state I.,vtolating to PHRMI'EISSUANCH MECI IANICAL FEE
Lam+ building construction,and hereby amhorim reprcsemetives fthie city tomer upon the CONSTRUCTION TAX
V z Nice mentioned proper,for inspection purposes. ALTER OR ADD TO MECH.
(We)Agree m save emmfy and p hurmle.e a City of Cupeninn against
lishilities,j g an c is t sora, c myna wayumruengains Aid Cyy AIR HANDLING UNITfI�1,B
incon nc of this tit. �/
I( AIR HANDLING UNITGVHR 10,000 CPM)
Signature of APPliwntlContmetor One EXI IAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA3'ING UNIT(TO 100.001 BTU) Date Receipt#
Will the applicant or future building occupsnt.tote of handle haysedous material
as defined by the Cupevian Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER ,(010 BTU) TOT
Calc,Section 25532(.)?
❑Yes 11 No I VRN'1'ILATI2N I 1. P.SID) I
IIX),IXIOB
ISSUANCE DATE
Will the applicant orfmurc huildingphupant usecquipmemonlevias which emit BOILER-COMP
bamtdous air contaminants as defr,d by dre Ray Arca Air Quality Marvigmirent ROILIEIt-C h OVER IIX U) �,
District?
❑Yes ❑No SI IENTIAL MECY. FT, sj
I have read the aceardous materials requirements under Chapter 695 of the JUN 08 1995
California Health&Safety Code,Sections 25505,25533 and 255.4.I undentwd the
if The building docs not currently have a cant[,that it is my responsibility to notify Ne V / C11 y
occupant of the requirements which must be met prior to issuance of a Certificate of f 1 Ut- (;Up
Occupancy.
Owner or authnried agent Date i'e TOTAL: ISSUED BY:
Q