28192 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-N,LKC'I RICA], PERMI'FNO, atea�
APPLICATION/PERMIT PLUMBING-MECHANICAL" '2 l8 L
BUILDING DIVISION BUILDING PROJF,CT IDENTIFICATION
B ' MING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL CAI E
C. 4W Rj I 'Ni-r# LOT# 6�.g
OW SN is PHONE. CO A )R'S NAME. LIC NO: NIC V COM'♦♦RUE,A
11iC I VdIdAEIiR: LIC NO. ADDEl✓9� /1I, r cue c_
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELEL'TRIC PERMIT' FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE. ❑ ate,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN IAL J`OIRE DliSCRIPI'ION
G eeZ. I hereby affirm that l am licensed underpmvisionsofCbapter9(commencing with
+10F0 Section J000)of Division 3 of the Business and Professions Code,and my license is in PANELS
edfull force and effect
<" License Class Lic.is UP102W AMPS
m?y Dee Continue 201-10110 AMPS SQ.Ill FLOOR AREA S/SQ.FI'.
ZOyz ARCHITECTS DECLARATION OVER I"AMPS
0 Z_C 1 understand my plans shall he used as public¢cams.
F H l—W SIGNS ELECTRICAL.
Qy$j d Professional
P4NVerse
,=Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOp,U 1 hereby affirm mat 1 am exempt four the Coommu rs License law for the
mat+-y following meant,(Section]0315,Business and Professions Code:Any city or county TEMP.METER OR MOLE INST.
F40�' which ma,m es a permit to construct,alma,improve,demolish,or repair any sweure
�WYS prior o its issuance.also requires the applicant for such permluo file a signed statement POWER DEVICES
C0.6 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
e,Og Oo� 9(commencing with Section 7000)of Doision3ofine Businessand Mofcssiuns Cute) SWIMMING POOL ELECTRIC VALUA'T'ION
W—y or shat he is exempt therefrom and the basis for the alleged exemption Anyvinletinn of OUTLETS-SWITClHS-
F-Z, Section 9031.5 by any aPpl icunt l or it aroulcubjeeN the applicant to a civil penalty of FIXTURES
not am than five hundred dollars($50x0).
E—O NEWRESIDENTIALELECTR SQ.FT.
CCS ❑ otbe wrk,anthestreny,orm otimeadmil yeeawlthened mraic(Selecompemetmo, STORIES TYPE CONSTRUCTION
a3— will daahewons Codec he Contractors
Lienee Law
fs not apply
to an
ness
Coe Professions code The Comracmr's Liccmc law ewe not apply m an owner of
property who builds or improves thereon,and who dues sock work himself or through his
own employees.provided that such improvemenam
anm intendedoroffered forsale.If. OCC GROUP RES.UNII'g
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that be did not build or improve for purpose of
sale')' QTY. PLU NO PERMIT FEE FLOOD ZONE APN
❑ I,aaownerotthe Mol ay.un% xclusivelycunlrt¢tingwithlicensedconuactomto
construct the project(Sec.7041,Business and Professions Code:)The Comossaa.
Livens Law does not apply manownerefpropeny who builds or improves thereon,and PERMIT LANCE
whomntmau forsach pmjttts wise aconhactogs)licensed pursuant m the Contractor's
License Law. AirTIER-DRAIN&V ENT-WATER(I:A) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for pis BACK FLOW PRO E(Tf.DEVICE OUTSID:FIiE.
SANITARY Y N
s Owner UamDRAINS-FL ,ROOF,AREA.COND. RECEIPI'p
WORKMAN COMI'ENSAI'ION DECIARATI SCHOOL TAX YN
❑ Thereby effirtn lhmlbave accniliwlc of cnnsOamself-1 um macenificctcof FIXTURES-PERT P RECEIPT#
Workem'Cumpensation Insurance nraceni0ed copy eerco(( c.3gOBLab C.)which PARK IEE YN
covers all employee's under this permit. GAS—N.Sl i 6C.4 DO[L, S RECEIPT#
Polley X BUILDING DIVISION FEES
Company GAS- S TEM-OV 4( Y PLANCHECK ME
❑ Cenifed cup,is hereby l umished.
❑ Certified copy is fled with the city inspection division. t NDUST ASTEIN',RCEPTOR GRADING FEE
CERTIFICATE 01;EXEMPTION FROM WOR ERS' EASETRAP / SOILS FEE
COMPENSATION INSURANCE
(This section need not he rompldcd if me permit is far uneh dred Jolles( SEWER-. I'I' RY-STORM E.A.200FT. ENERGY FF:I?
or less.)
I certify that in the performance ofthe work fm which this pc lis issued.O SM1aII WATER]PLAYER W/VEMfpiLliC1R
not employ any peon. in any manner w as to become sahject o the Workers' PAID
Compenmtionlawsof Califomia. Date----------- WATER SYSTEM/TREAT G Date ecelptif
O Z Applicant
Z0 NO I'ICE TO APPLICANU If,are,nickimy this Certr.mor Eumptin youahaold NEW RESIDENTIAL PEMB. SQ.FT. TO
VO Iucomc subjccnuthe Worker's Cnmpcnsmion pmvisiom of the EaborCM you must
� ; forthwith comply wise such provisions or mis permit shell be JcemrA rtvokc BUILDING I"E
M1Wi [� CONSTRUCTION LENDING AGENCY z
SEAS 13
Z I hereby affirm that hem is a constrvetion lending agency for the perfamunce
U O the work for which this permit is issud(Sec.309'!,Civ.C.) TOTAL: ELEC' C P iii
Lenders Name PLUMBING
W F leader:Address QTY. MECHANICAL PERMIT PEE
U 1 certify that 1 have read this application and state that the above information is MECHANIC L FEE
W correct A agree to comply with all city and county ordinances and.sum laws miming m PERMIT ISSUANCE
hu Idmgcnnstrvaio0 andhereb amhonzerepresn sof eiscity mercer upon the CONSTR =ON TAX
U Z aWvcmeof coed property fo pectin ryas 've LIER OR ADD TO MECH.
(We)agree eve, a oily cep ndcss me City of C nino agar t
liebililies.ju c s, mxpe ex hi may inanywaymr ainst said it AIR HANDLING UNIT p'O It1,IXX)CFM)
err thesos AIR HANDLING UNIT(OVER 10.0110 CFM)
m ncc ✓ �
Si n m hApplicanhComrunnr Dam EXHAUST ROOD(W/DUM) PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO If10.W0 BTU) D Rcccipt#
Will the applicant or future building accentual stun or handle hmardous material HEATING UNIT Gal ER I Ot BTU)
for defined by the Cupertino Municipal Code,Chapter 9.12,and the I lealth and Safety TOTAL:
Code.Section 25532(4)'! VEM'ILATION 17AN(SI NGLF,RESIDE
❑Ycs ❑No
SISSUANCE DATE
Will the applicant or future buildingcecupant uualuipmenmrdeviveawhichemit BOILER.COMP(311P OR 100.01M BTU)
washout air contaminants as definW by the Buy Area Air Quality Management BOILER-COMP(OVER 100,f)(00 BTU) JI/Al -#
District? 1
❑Yes 13 No NEWRESIDENTIALMECIL SQ.FT. 1995
1 have read the hamadous materials requirements under Chapter 6uS of the
California Health&Safety Code,Sectiom 25505,25533 and 25534. I unJemand that urC
if the dinHe m,m t currently have a,,he,the it u my tapmeibf.Ce nrnify me
occupant of ec rcyam currev which mast be met nnos ar istoance ora Certifiof
cate
Occupancy,
Owner or amM1orise agent Dam TOTAL: ISSUED BY:
OFFICE