26673CITY OF CUPERTINO APPLICATION/PERMIT I'LUMRING-MECHANICAL 266731
BUILDING DIVISION I— BUILDING PROJECT IDENTIFICATION
"......
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
I hereby affirm that I am licensed under provisionsof Chapter 9 (commencing with
comtruc the project (Sec. IR4, Busi a Pr es tons Cade:) The Con tore
as
Licenscl, wdowsum applyl an u e whohuild rhe ,and
nc
ictied7000)of Division J of the Business end Professions Code, end my license is in
e
PANELS
n force and effect.
License Class Lic.#
UP TO 2M AMPS
201 - 1000 AMPS -
Date Comm,
ARCHITECTS DECLARATION
OVER 1000 AMPS It
WORKMAN COMPENSATION ON
❑ thereby. umthatlhaveucmif¢arem' senuoself-insure,or4ccrtificateof
Wrrken'Cand, samionlnsuranceorecerf copy thromf(Sec. 38M, Lab C.) which
I numeration my plans ahNl be used ns public reemds.
SIGNS ELECTRICAL
cmera oll vnplo 's under Nis perm
Policy #
LicrnsM Rofe4siond
Company
OWNER -BUILDER DECLARATION
SPEC CI UIT I C.
I hereby d. (Se that 1 am exempt from the Contractors Co Lic Lew for the
following reason. (Section 70JL5, Business vW Pra(maions Cod y ty ar ca
R
Lure
ssnrecanswe titer, improve,demolis impair yswment
which its issuance,the applicanfareoch pe mLicon gn statement
Erin
PO R E
I
he is licensed pursorequires
that he is license. p Sectio ro the provisions of the C moor's L Parr (Chapter
(commencing Division eBnsinem and.Any ons Code)
9that
S MM O `POOL ELECTRIC
S - SWITCHES - FIXTURES
he is therefrom add the
Sor ectioheisex by ap I and the arthealleged exemption. Any option of
Section 90]1.5 by any ep I' a pemrib subjects the epDlicenm bo a civil vlty of
NEW RESIDENTULL ELECIR _SQ. PI'.
not mom than E dollen (5500).
❑ Les emOhepropcny,mrayemDloyeeswidh wogesastheirsalecorn nation,
('P his section peen not he completed ifthe permit is for one hunNeddollars($100)
wilIdo ework, and thesmructure is not inendedmoffemdforsale(Sec.1044, usinesa
end femions Code: The Commerce. License law doe not apply n m r of
WATER HEATER W/VII/ELECTR
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pmpe y whobndamimprovearhemon, and whodoes such work himselforth ugh his
anot income offieredfa ole. if,
own nlovees. provided that such improvementsre
NEW RESIDENTIAL PLMB. SQ. FT.
FEE
FEE
FEE
PARK FEE
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
FEE SUMMARY
ID' EES
Y N
RECEIPT M
Y N_
RECEIPT #
Y N
RECHIPT#
LDING DIVISION FEES
-/liK �
PAID
Date Receipt#
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING IEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Dore Receipt#
TOT
P p I NUANCE AT
JUN 3 0194
7Y Ur L,UrCtiIIIVV `J
ISSUED BY:
huilde will have the buMcn of proving that he did not bu'dmimprovefor real
sale.).
❑ I, rafbhe property,amez<lusive ith licensed con ono
QTY. PLUMBING PERMIT
comtruc the project (Sec. IR4, Busi a Pr es tons Cade:) The Con tore
as
Licenscl, wdowsum applyl an u e whohuild rhe ,and
nc
PERMIT ISSUANCE
who cont. fmsuchp 'e w tracmr(s)liceyydp rata
License La -L✓y
❑ tames cap, under Sec. 8 & f this reason
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
-
Owner °reLARATI
DRAINS. FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION ON
❑ thereby. umthatlhaveucmif¢arem' senuoself-insure,or4ccrtificateof
Wrrken'Cand, samionlnsuranceorecerf copy thromf(Sec. 38M, Lab C.) which
FIXTURES - PER TRAP
GAS . EA. SYSTEM -1 INC. 4 OUTLETS
cmera oll vnplo 's under Nis perm
Policy #
Company
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Cenifled ropy y famished.
GREASFANDUSTRL WASTE INTERCEPTOR
❑ CenifirA copy is Bled with Ne ciry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
('P his section peen not he completed ifthe permit is for one hunNeddollars($100)
m lay.)
I cenifytbm in the perfmmance ofRa work far which this permit is issued, lshell
WATER HEATER W/VII/ELECTR
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note lay any Person in my so e; m o e L. t )o he Wmkets'
C nutionLLawalife �4z y� J 'Y
pplicanr W:
NOTICP. �A�ICANT: If, after making this Ccnifirare of Exemption, you shoulJ
became subject to the Workers Compensation provisions of the labor Cade, you must
WATER SYSTEM/IREATING
NEW RESIDENTIAL PLMB. SQ. FT.
FFa
forthwith comply with such pmvisiom or this permit shell be domalrooked.
W
2
CONSTRUCTION LENDING AGENCY
i hereby affirm that there is a conswction lending agency for the performance of
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V)
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the work for which this penrat is issued (See. 3097. Civ. C.)
Lender's Name
QTY. MECHANICAL PERMIT
Lenders Addreaa
I Sonify that 1 have read this application and some that the above information ie
Soman. I agree to comply with all city and county abdomens it state laws relating to
building construction, and hereby euthadtt reprtuntefivaof Nie city mentor upon the
above.mentioned property for impaction purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way ace.e against said City
AIR HANDLING UNIT(TO 10,0(XI CFM)
in cumeyvence, of the granting of this permit.
AIR HANDLING UNIT (OVER Igt100 CFM)
EXHAUST HOOD(WIDUCD
can# o .Snot Dam
HEATING UNIT GO Ift" BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building raccoon abort or handle hazardous materiel
m defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE REBID)
Codo, Secti❑ Yes 25532(a)?
C1 No
BOILER- COMP(3HP OR IOBgp BTU)
Will the applicumorfulumbuildingoccupant useemipmem ordevices which emit
mountain au contaminants m defined by the Bay Arca Air Quality Management
BOILER - COMP (OVER IM." BTU)
Dismal
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yca ❑ No
I have read the harardma materials requirements under Chapter 6.95 of the
California Health & Safety Coda Sections 25505, 25533 and 25534. 1 understand that
if the hullding does not currently have a round, that it is my responsibility to notify the
cupan of the requirement which tomb be and prim to isau sine of a Crumficne of
Occupancy.
Owner or auNorited agent Dote
T A
FEE
FEE
FEE
PARK FEE
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
FEE SUMMARY
ID' EES
Y N
RECEIPT M
Y N_
RECEIPT #
Y N
RECHIPT#
LDING DIVISION FEES
-/liK �
PAID
Date Receipt#
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING IEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Dore Receipt#
TOT
P p I NUANCE AT
JUN 3 0194
7Y Ur L,UrCtiIIIVV `J
ISSUED BY: