26077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONBUIL"Nls E - PERMIT ND. O
APPLICATION/PERMIT PING PROJECT MECHANICAL
BUILDING DIVISION BUILDING PR(ARCI'IDRNfIFTC.A'1'I(IN
PUILDING ADDRB55: �` 77
SANITARY NO. APPLICATION SUBNUTTALDATE
O V zm Ivy LOT N {/
O N NAMN PHO /p CONTRACTOR'S NAME - LIC NO: / NIC CONTROLN
IlA r
AR 111 /ENGINEER: LIC NO: ADD �!' / � ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OmZ I hereby affirm that l ma limared under provisions ofChaptcr 9(commencing with JOB DESCRIPTION
pU00 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
FF full force and effe r
Dole It Class �� Lic.# c__� UP TO 2M AMPS
H d Date Convector 201-]BOB AMPS
or Z_ CHITF.CTS DE RATIO SQ.PI'.FLOOR AREA S/SQ,FT,
OZ-0 IunderstandmyphimahaRbe urdup i Na. OVER 1(100 AMPS
f:4.uYn �{ SIGNS ELECTRICAL
iJ{��; ] Licensed Professional
QQ OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MIgC.
NW 3 t0.U I dfirch(Se that I am exempt from the Contractors o e:Any law for the
following reason,(Section combat Business and Professions Cede:Any city or county TEMP.METER OR POLE INST.
C
which requires a pesmim m combat Business alai,improve,demolish,of repair my swore
;!(}� prior mo its issuance,also slaves Neapplicmt forsuch pennitm EleasignW ruammt POWER DEVICES
1y_¢Oq that he is licensed pursuant to the provision of the Contractors License law(Chapter
oLL 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
µ'jay or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURES
QSection]031.5 by any applicant for a permit subjects the applicant to a civil penury of
G 0 1,a than five ofthephundred dollarmyemp, NEW RESIDENTIAL ELECTR -SQ.FT. STORIES TYPECONSTRUCTION
yK m ❑ o the wnemftheproperty,ormytmpl"yeaswiNwed farsidei(m.mlBusiness
will do thework,and the Theureisnor is ended Ufacrom Lateral farside
n,an Business
and Profusions Code:The Contracmra lactose law dos mm apply lf rt owner ofis
propmywhobuiIms idmprovalhi on,adwh"dousuch w0 do, ffef (roue.If. OCC.GROUP RES.UNITS
ownemployces,providedth lluroveh ent is sold
wit arenot Iended"(pletioE fosale,lf,
however,the
have
the
burden
ofpmcm is sold a didnor year ore prove for t purpose
of TOTAL:
builder will have the burden of proving char he did nor build or improve for purpose of
sale.).
[1I,as ownerofthe property,an exclusively contracting with licensed convectors to QTY, PLUMBING PERMIT FEE F100D'LO E APN
construct the project(Sm.7044,Business and Profession Code:)The Comructora PERMIT ISSUANCE
wcu
License Law dao not apply m m own(of property who bus Ids m improves thereon,and
who c0nfor such projecu nw
with a coemr(s)greated pu muntto Ju Conuacmrs ALTER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
cu
❑ I am exempt under So. B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y DN
oono pati RECEIPT'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby'ComparcutN ImmatuI have re
anifierteofcoucmmnof(Sm.380.Lab C.) hickte of RECEIPT'#
FIXTURES-PER TRAP
W"rken'Comprnmtinn lnurmce macertificd copy Hereof(Sm.3800.Lab C.)which PARK FEE 'Y N
rs all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTL RECEIPT#
Policy If I BUILDING DIVISION FEES
"Y GAS-EA.SYSTEM-OVER 4 ElkPLANCHECK FEE
Certified copy is hereby famished,
❑ citified copy is filed with the city inspection division. GREASFJINDUSTRLWAS CEPTOR GRADING FEC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRI SOILS FEE
COMPENSATION INSURANCE
(This section aced not be completed ifthe permit is foram hmdred dollars(SIM) SEWER-S T Y- MEA.20l ENERGY FEE
orless.)
I certify that I.the othfimmmceofthe work for which this pewit is issued,l shall WATER HEAR /VENT/ELEC7R
not employ my person in my manner s"as to become subject to the Workers' PAID
C"mpensution Lawsof Califnnia. Data WATER SYSTEVRENDNO Date Receipt#
O Z Applicant
Z NOTICE TO APPLICANT:If.after melong mist Cadifieehaof Emmpd"n,y.0 should NEW RESIDENTIAL PL.MB. SQ.FT. TOTAL:
16 becomesubjat to the Wmkcrs Compensation provisiomof Ne labor Code,you most
forthwith comply with such provisions or this Permit shell his domed invoked. - BUILDING FEE
W Q CONSTRUCDON LENDING AGENCY SEISMIC FEE
z hereby affirm that there is s conswetim lending agency for the perfmmmce of
U C) the work for which Nis permit is issued(Sec.3097,Civ.C.) CLECIDUC FEE
Lenders Name
,O Lenders Addrns QTY. MECHANICAL PERMIT FEE PLUMBING FEE
T cenify,that I have mad this application and sum Net the above inforaation is MECHANICAL ME
correct.l agree to comply with all city ad county ordinances and shame laws mlating to PERMIT ISSUANCE
VI building construction,ad hereby amhorim representatives ofthis city to enter upon the CONSTRUCTION TAX
7
V G above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify and keep h sonleas the City of Cupertino against
liabilities,judgmenu,cosumdexpenseswMchmayinmywa eccmeageimI 'd Ciy AIR HANDLING UNIT(TO 10,WUCFM)
to consequence of the granting of this pamim.
AIR HANDLING UNIT(OVER I0,000 CFM)
igm of Appli mUConvect"r ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.010 BTU) Dote Receipt#
Will the applicant or future building ocupant atom Brhmdle huallous rnmriel HEATING UNIT(OVER IW,000 BTU) Tn L:
as defir d by the Cupertino Municipal Cade,Chapter,9.12.and the Heart and Safety
Code,Sotian 25532(a)1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANC A E
Will the applicantorfuure buildingocupmtuseequipmentordevices which emit BOILER-COMP LIPP OR M."RTU)
norms air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) R'I
Clishoth,
Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
J 1 have mad the haysrdous materials ragoimmems under Chapter 6.95 of the n = 2 199
Carrara.Health&Safety Coal,Sections 25505,25533 and]5534. I understand Nat
if the building dos not currently have it tenant,that it is my responsibility to nmify the `
occupant of the mquinmems which must be met prior to issuance of a Certificate of GI'
Occupancy, II J
Owner or aathodrd agent Data TOTAL: ISSUED BY:
OFFiCE1 -