28052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY PP CUPERTINO B ILD;\G-LITCOUCAL PERMIT NO. 28052
APPLICATION/PERMIT PLUM NG-MECHANICAL BUILT)IA'G DIVISION BUILDING PHOJECTIDE:NTIF'ICATION
BUILDING ADDRESS: ` I T SANITARY NO. APPLICATION SUBMfffAL DATE
2 UNIT; w LOT# S-16-Q S
O NE AME \ PITON CONTRA R'S 14Af1Pjit) � LIC NO:
i N SIC CONTROL#
\RCIHTE I'/ENGINEER: LIC NO: )RF : s- • T .—
CONTACT PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG PLUMB II
MEC
PERMIT ISSUANCE' El
LICENSED C.ON'IRACPOR'S DECLARATION APPLIANCES-RESIDENT'IAl. Q{�1)(�,SCggllyyyyON
py.Z Ihc,ebyalfirmlhat lam licenscA under pnrvisionsofCM1apmr9(commcncing with
W00Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
W02
edE- full force and effeUct. UP TO 2W AMPS
FZW Dole cClss Lick
m j y Dam Cnnaracmr 201-I IKKI AMPS SQ,PI'.FLOOR AREA E/SQ.FT.
ZI o,z ARCHITECTS DECLARATION OVER 1000 AMPS
O Z-- I understand my phare shall be used s public records.
FmFW SIGNS ELECTRICAL
�.Wi Licensed Proressiond
�M< OWNER-BUILDER DECLARATION SPECIAL CIRCUCOMISC.
kOaU I hereby affirm that 1 am exempt from the Committers License Law fm the
W 3 W m following reason.(Section 9031.5,Business and Professions Code:Any cityof county TEMP.METER OR POLE INST.
O; which requires a permit to construct.alter,improve,demolish,or repair any structure
r:F prior to its issuance,also requites the applicant for such permit o file asigned smtement POWER DEVICES
tiWW< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapmer VALUATION
ga9 9 with Section 700o f Division 3 of Business and Professions Code) SWIMMINGPOOLHLECTRIC
XX (commencing wi )n
ty_,� nnhm he is exempt therefrom and the basis for the alleged exemption.Any situation or OUTLETS-SWITCUES-FIXT'UR
b-Z G Section 7031.5 by any applicant for a permit subjects the applicant to t civil penally of
mol more Than five hundred Dollars(E5W).
q NEW RESIDENTIAL ELEM _SQ.FT. STORIES TYPE CONSTRUCTION
Lc � ❑ Lnowncfofthepropeny,onnyemployces with wages astheirsolecnmpcnsantn,
will do the work,and dic,ameame N not intended oroffemd forsahe(Sec.9004,Business
and Profession Code:The Comractnra License law does not apply to an owner of
property whobuildsorimproves dommin,and whodtes such work himselfof through his OCC.GROUP RES.UNITS
hoemployeesilding edthm svemeris roimentamenor earofdo pleflod the owner.
wever,0e building m improvement is hand within one ream completion,the owner- 'fOTA
huildcr will M1ave the burden of proving tM1at he did no.build nr improve fm purpose of
salt.). QTY. PLUMBING PERMIT .P FLOOD ZONE APN
❑ Las owner ofthe property.an exclusively contmctingwith licensed contractors to
construct the project(Sec.TOGO.Business and Professions Code)Ili Contractor's
License Lawdoes not apply to an ownerufpropeny whobuildscrimproves therem.and PERMIT ISSUANCE
whocomructs fersucb projects with steno-clods)licensed Incurred to the Contractors
Licmue Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY
FEPS
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOp.AREA,COND. RECEIPTN
I\ WORKMAN COM PENSATION DECLARATION SCHOOLTAX Y N
t ❑ I herebyuffirm that l have a certificate ofennsenl a..If asufe,or u cenlficme ofRECE 'I'p
k
Wmes'ComIx,malion lnurare
nce or t nified ropy Neretf(Set.3800,Lab C.)which FIXTURES-PER'LRAP PARK FET: Y N
Pall employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLET BE IPI'
o n cy k BUILD[ 1 ISIOh FEES
Company GAS-IA.SYSTEM-OVER 4(EA) PLANCUECK FEE
❑ Certified copy is hereby Intrusted.
❑ Cenifedcop isfhedwithlhecityinspectiondivisinn. GREASEINDUSTRL WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OIr EXEMPTION FROM WORKERS' GREASE TRAP SOI LS FEE
• COMPENSATION INSURANCE
(This aecfcm.esJ not becmnpleed iftbe permit is for one hundred doll.(EIW) SEWER-SANITARY-STORM E.A.2001T. ENERGY FTE
les.)
I cenily that in the perfommnccofthe work fm wbichthis permit irisstted,Ishalh WATER HEATER WNENT/IiLIiCR
not employ any pawn in any manner so ax to become subject m the Workers PAID
Compenaauonlawsnf Califomia. Dam WATER SYSTEMaREATING D.%,j
Q z Applicant
z 0 NOTICE 10 APPLICAN'1':If.idue,makingthie Cenifcmeof Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
I--' y
fttomccmpythe Worker's Compensation provisiontithe Ias!inCode,you must
� � forthwithhcomply with such provisions or this Permit shall Mdmed eevoked. BUILDING FTE
a [�
CONSTRUCT ION LENDING AGENCY SEISMIC FEE
z I hereby affirmtltmthein iso crusumelion lending agency fonue pcdormanaof TOTAL: ELECTRIC FEE work fur which this permit is issued(See 301P.Civ.CJ
t benders Name TY. MECHANICAL PERMIT' FEE PLU
Lender's Address Q MBING FT
U I certify that I have read this application and sat c that the above lot ommiion is MECHANICAL 'EE
correct.l agree to comply with all city std county ordinances and state laws relating to PERMIT ISSUANCE
F" brldingcnnavucd,rimd herebyu n ze representatives ofthiscity mercer upon the CONSTRUMI(NTAX
V z slaw,-mentioned propeny tor' sperm n Pugto. x. ALTER OR ADD TO MECII.
agree to e,inJ nmify an less the Ciry of Caperton against
Iabihiuea, rata# cxpcns any way accrue against said City AIR HANDLING UNIT(TO I0.000CFM)
c cof a rami sof ah' it.
AIR HANDLING UNIT(OVER 10,011(1 CFM)
Sigoautre of Ap nonVComractnr Da EXHAUST HOOD(W/DUC) PAID
I IAZARDOUS MAI rRIALS DISCLOSURE. HEATING UNIT(TO 100,000 BTU) Date Recciptk
W.
the applicant or future building mention stem or bandlehmnrdous motorial HEATING UNIT(OVER IWdWr)BTU) TOTA
s de W. b e the Cupcnino Municipal Cade,Chapter 9.12,mad the HeaIN and Safety
Code,Section 25532(1 0'! VENG H ATION PAN(SINGLE RPSID) C
❑Yes ❑No
a Will the acommurcontor or as defined by the Bay Alyea Air tnuality Management q
BOILER.COMP(3HPORIW/XIOBTU)F911ISSUAN ATE
nardous air contaminants s defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) U"
Distrix! A ! Pa
❑Ya ❑No NEW RISIDEN'1'IAL MECII. SQ.FI'. (�oppp,{�/.x • RJ
1 have read the hazmdous materials requirements under Chapter 6.95 of the ,./QY / 0
Czlif.r I health&Safety Code,Sections 25505,25533 and 25534. 1aide rstand that •3 199
if the building does am currently have a acr am,that it is my re,ponsibihity to notify the
racialism of the requirements which most It,met prim to issuance of a Cenificzm of /7),
Or,caPamy.
Owner muth
ueriuJ agent Date TOTAL: ISSUIiD BY:
OFFICE