28002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIJOtNU ... 1H A. PERMIT NO. n o //�
APPLICATION/PERMIT YI,UMIIING-MECHANICAL 2 O O O
BUILDING DIVISION BUILDING PROJECP IDRN'n F'ICAIION
BUILDING A�DD/RE�S/5:��'} SANITARY NO. APPLICATION SUBMITTAL D
ATE
10 LOT# `L—TI -40(
CO TrJ LIC NO:
�_ NIC CONTROLp
ARCHITECT/ENGINEER:
LIC NO: ADDRESS: El I
CONTACF: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E ❑
PI,UMU MICII
PERMIT ISSUANCC I�Yt�a'rl��Fifty
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB UPSCR 'By'(y'1L/1_
cwz Ihereby effitmthai l am rocnmd under pmvisionsol'Chapmr9peomme sing with yl� is \ IfVJ `G/`y
n00 Section'1000)af Division 3 of the Business and Professions Code.and my license is in PANELS {`il�Cs'Y1_
W full fierce soul effect.
U V Lie.is UP TO 200 AMPS
cA<eZ License Class coot
vt,Q]y Date ConTS Dr OV201 ER
100000 AMPS
SQ.IT.FLOOR AREA $/SQ.FT.
CZEy, ARCHITECTS he CTS DECLARATION OVER IIXXIAMPS
O Z�❑ I undcrvand my plon.ti ahull M1c avatars public records.
FyF j SIGNS ELECTRICAL
Q J Licensed Professional
�Owu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Ka1 hereby affimT that 1 am exempt from the Contractor's License Law fnr the
IL3Y-v~i following renson.(Section 7031.5.Business and Professions Code Any city or country t'EMP.MEfF.R OR POLE INST.
which requires a permit to constrict,alter,improve,demolish,or repair any cure
}�
al,plicard forsuch Eamtiuofile esi ted stmemenl POWER DEVICES
priorToits soance.oh.Taconite,he
Q O that he is licensed pursuant to the provisions of the Cnmmcmr's License Law(Chapter
m O SWIMMING POOL ELECTRIC
d LxaLL n(rommeis(commencing with Sections I0110)heDivisionioflleed exoneration.
Professions Code) VALUATION
p1_y or That he is enempuhertfrom anJ the basis fonhe alleged exemption.Any violation of Ol1TLETSSWITCHFS-FlXTURES
F-$Q Section 7011,1 by any apphraim for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(SSW).
M NEW RESIDENTIALELECIIi _SQ.FF. STORIES TYPE CONSTRUCT ION
to:— ❑ I,avownerofthepmpeny,ormyemplo mswithwogesaslheirsolerompemauon,
M' o will do the worLand the structure is not intendcdoroffered forsale(Sec.1044,Business
and Prine.Wnns Code:'I'hc Conlracwrs License Luw docs oat apply m an owner of
Property whobuilds or improves Ihereon.nnJ whodaes such work himselfor Nroughhis
OCC.GROUP RES.UNITS
emFlnyees,p building
or ithauucri improvementin ne mmndWoroffered for sale.If.
bWwcveq the The for den of pmentishat he diinoneywr or improve
Forthe owner-urposof T r�
builder wlll bout the hunters a!proving that he did not build or improve far purposo a[
'sale")'
❑ Lasawnerofthe property,aro exdusivelyconvacting with licensed convacmrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
vnswa the Prnjccl(See.I044,Business shad Prolesxions Care:)TIT,Contractor:
License Low does not apply to an owner of property who builds or improv es iherem.and
PERMIT ISSUANCE /
who comments forsuch projects with aronuaa trod liunsed pursmmuo the Con memr's
License Law. ALTER.DRAIN&VENT-WATER(FA) PEE SUMMARY
❑ 1 um exempt under Sec. .D&P C for this reason OUTS D;FEES
BACK FLOW PROTECT..DEVICE IT
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF AREA.COND. RECEIPTx
WORKMAN COMPENSATION DF,CLARAIION SCHOOLTAX YN
❑ Thereby affirm th:n lhave ucenifcam of consntm�el�-insure,Qrnccni le of FIXTURES-PER'IRAP RECEI PTk
WorkerACompeasalion Insurance or a certified copy Ncreaf(Sec.Jg00.La ich PARK FF,E Y N
covers all employees under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT 4
poliey X BUILDING DIVISION FEES
Company GAS-EA,SYSTEM-OVER 4(EA) PLANCIIECK FEE?
❑ CertiOedcopynherebypumisbed. ���///��X
❑ Cmifiedcopy is filth with the city parsecni divisOn.\ EASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPI'10 /WORKER ' \ GREASE'[RAP SOILS IEC
COMPENSATION INSU NCE
(Thisseaction meed not becomplelW ifthe perm: i foronehun II (SIM) SEWER SANITARY-STORM EA.200fT. ENERGY FEE
or less.)
Icenifythminlhe performance of the workfar ch This permit is issued,l shall WATER HEATER W/VENT/ELECFR
not employ any person in any manner so as m become subject m the Worker: PAID
CompenamionLossof Califomio. Data WATER SYSTEM/IREATING Dam Receipt#
C) Z Applicant
Z O NOTICE:10 APPLICANT:IL after making this Cenilicate of Exemption,you should NEW RESI DENTIAL PLMB. SQ.M. TOTAL:
^ become subject to the Worker's Compensation Provisions of the labor Cade,you must BUILDING FEE
a > forthwith comply with inch pmvisions or this perniuhall be deemed revoked. /_
6w. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a contained.[ending agency for the performance of
U T thew..rk for whichoti,permit is issued(Sec.309],Civ.C.) T S ELECTRIC FEE
Lender's Name
u"' F Lenders Address QTY. MECHANICALPERMIT FEC PLUMBING FEE
U I terrify that I have Tend this application and sone That the above infornmicn is MECHANICAL FTE
>� correct.Igree Tocontply with all tiny and county ordinances and sore lawsrehiing to PERMIT ISSUANCE
buddingeonmuction.and hereby auNorive representatives of Nis city menter upon the
fq CONSTRUCTION TAX
V Z above-mentioned property for indemnify
inspection keeppurposes. ALTER OR ADD TO MECH.
(We)agree n save,indemnify and kap may i a y City of Cotentin.mmagainst
liabilities,judgments,costs unJ expenses which may in any way accrue againm said City AIR HANDLING UNIT(TO 10,000 CFM)
14.in of The granting of Nis permit. S/
3 Q AIR HANDLING UNIT(OVER to."CFM)
'iganm pplitam/Cordewor More EXHAUST HOOD(W/)UCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,W0 BTU) Dam Receipt It
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,auditor Health and Safety HEATING UNIT(OVER IIp,1X10 BTU)
16
Code,Section 25532po? VENTILATION FAN(SINGLE BESIDE
❑Yes ❑No
ISSUANCE DATE
Will lheapplicanlorfmumbuildingmcupantn¢equipmentordeviceswhichemit BOILER-COMP(3HP OR 1110,000 BTU) PAID A I D
hica dons air contaminants us Jef ed by the Buy Area Air Quality Managanent BOILER-COMP(OVER 100JLO BTU) tl'�
fishnet? nn
❑Yr, ❑Na NEW RESIDENTIAL MECII. SQ.FF. MIS y A ��
1 have read the hard
zaous meqreme
aterials ruims under Chapter 6.95 of the C// all r `x ak
California Health od
&Safety e,Sections 25505,25533 nod 25534. 1 understand that la y k�
ifnhe buildingdoes not Ironically have a tenant,that h is my responsibility tonotify the r Ur Liu
occupant of The mqu carr erts which must be,mel prior to issuance of o Cer ificale of
Occupancy.
Owoernr umhorircd agent Date TOTAL: ISSUED Ii .
OFFICE