28178 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 7
CITY OF CUPERTINO ILUMB NG-XLEC MECHANICAL 1'IiItMIT NO. /�81 1 H
APPLICATION/PERMIT PLIIMBLNI:- RCA G
IIUIG ADDRLDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AUDRFSS: �//���j /`(L,/) ///� �1/� � SANITARY NO. APPLICATION SUBMII//'1��ALIIA'lli
/07c;73 . —,66 e— I / ,4C o= 11NIT# LOl'M
.Wb., ME: PHONE: CO ACTOR:SNAME: LIC NO: N� CONIROLp
J H ✓LGE I✓M6 VOwl
%RCHIIECHIBJGINEiR: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
Q'FY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MT:CH
PERMITISSUANCF; E p
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
�aZ l hembo
ymffirm that l am licensrdrmin,,rvisio.14Chapter 9(commencing with 10B IlIiSCRIPI'ION
POO S«tion 701X)of Division 3offlm Bmincaamd Professions Code,and my liceme is in PANELS
aCW� full fnce.ol cff*t3 ca, / 4o kt0I UPTO200AMPS 2Q�VP �F
FZ W License Class C• Li,b 10
m=y Dam Contractor 201-1000 AMPSSO.FT.FLOOR AREA S/SQ.IT.
ARCHITECTS DECLARATION OVER IM)AM
1 understand my plana shall IN,used as public records.
SIGNS ELECTRICAL
Q Licensed Protc,innal
y d'QOWNFR-BUILDER DECIARATION SPECIAL CIRCUIT/MISC.
KOy V L hereby affirm that 1 am exempt from the Contractors License Law for the
W'3Wy followingreanon.(Section 7031.5,Business and Professions Cud,Anycitymccunty 'IT:MP.METER OR POLE INST.
,—is which osaires a Permit to construct,abet,improve,demolish.or repair any structure
eg.� prior to its ismarea.also reclaimsmeapplicant fmmch Knot 1.flea si,ropel ammenr POWER DEVICCS
WR2 that he is licensed pursuant to the Provisions of the Contractors license Low(Chapter
g.'m 9(commencing with Section AXXB of Division 3 of the Business and Professions Code) SWIMMING POOL ELECT RIC VALUATION
W=oe or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
,ZQSection 70315 by any applicum fo apermi,.snbjcas the.,,tient m a civil penalty of OUTLETS-SWITCHES-FIXTURES
......han five hundred dollars($500).
=ONEW RE.SIDGU'IAL ELECTR _SQ.IT. STORIES TYPE CONSTRUCTION
uyu11F� ❑ ome w�rkoUhe mulffiroonsw,e iso ployeeswithw dfor lheirsole 044.Bs mem
and probewon,Corc: h,Com ep.a tic ml nr Law
do s lav apply Ilan,Business
rens Pmeaaiona cede The commamra Lfeea,e law a«snot apply In an owner or
pr.perty who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not lrtvmrdorefRrcd formic.If. OCC GROUP RES.UNITS
however,the buildingor improvement is sold within one yearof completion.theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sal..), PLUMBING PERMIT FEE ILOOII%ONE MIN
❑ I.azowneroftbepmpeny,amexclusivelymmmclingwithlicensedcontracmmm QTY.
construct the project(Sec.7014.Business and Professions Cod,)The Codmeor's PI7RMIT ISSUANCE
License Law Joesno,apply to an ewne—fIsodmoy who builds or improma thcrem,,end 0—
whocontmer for suchpmjects with a comract001)licensedp.mu.n,orheCcoloscom, ALTER-DRAIN&VENT-WATERIA
Licenselaw. ( ) FEE SUMMARY
❑ 1 am exempt undo Seu. .B&P C lin this maxon BACK FLOW PROTECT'.DEVICE— OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLUOR.ROOT,AREA,COND. RECEITg
WORKMAN COMI'ENSA'1'[ON DECLARATION SCIIOOLTAX Y N
❑ Ikrtby affirm lWllhaveacenificara of conxnuo ul(-insure,maanifcam or FIXTURES-PER TRAP RECHIPTIt
Worken'Compensmion Insurance.,.certified copy lhereof(See.3800,Lab C.)which PARK FFai Y N
cover,all employee's under This permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
BUILDING DIVISION I'Ii1S
Policy M
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city impc<tion division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS Viii
COMPENSATION INSURANCE
This section need not be completed ifthe permit is foronehundrod Jollms($10) SEWER-SANITARY-STORM EA.2017. ENERGY FEE
or less.)
I certify that in the performancesfthe work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECIR
not employ any ,on in any m ane,.t as to become subject m the Workers' PAID
Compeasationlswsof Califomia. Dates WATER SYSTFM/IRIi TING Dam Receipt If
Oz Applicant
.Z O NOl'ICE 10 APPLICANT:IL afar making(hisCertificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
C•-' ti berme subject o the Worker's Compensation previsions of the labor Code,you muss BUILDING FEE
forthwith comply with such pow isions or this Permit shall be deemed revoked.
aQ CONSTRUCT ION LENDING AGENCY SEISMIC PEI:
z I hereby affirm thauhem is a construction lending agency for the performance or ELECTRIC FEE
U O the wad for which this Perri,is issued(See 3097,Co.C.)
Lenders NamePLUMBING FEE 6
D" F Lcndues Address QTY. MECIIANICALPERMIT
FEF,
O U 1 certify that 1 have,cud this application and smm thin the above information is MECHANICAL ITE
>- correct Ino.n.comply with W)city and county ordinances and smm laws relming 10 PERMITISSUANCE
I—' building enomraetlon.and hereby amhorimmpresematives of this city bender upon the CONSTRUCTION TAX
U Z abnee-mentioned Propuny lin inspection purposes. ALTER OR ADD TO MECH.
(We)agmen.save,indemnify and keep harmless the City of C.1,14 a against
Iiahilities,judgments,costs and expenses which may in anyway accrue against said City AIR HANDLING UNIT(TO U."CFM)
to coasaquenee m dye gnarom,of Ida Pani. _ AIR HANDLING UNI'I'(OVER 10.0011 CFM)
Slgnmurtr pplicaMCovrucmr Dom EXHAUST HOOD IWNUCO
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,000 BTU) Dam Receipt g
Will the apPlicanlur suture huildmg necupanlstom or handle hae..do.,materialHEATING UNITrOVFR 10,00 BTU) 'TOTAL
defined ned by the Cupertino e,Municipal CedChapter 9.12,and the health and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RESID)
11 Yes 1:1 No I$ ANCD 1'E
Will thcapplicunmrfutumbuildingOccupamuscequipmetmordcviceswhichemit BOILER-COMPCHPOR10.0(g)BTU) 1995(][
�hamplous air comwminanu as defined by the Bay Area Air Quality Management BOILPR-COMP(OVER 100,"BTG) �VetlBB''1Ak,, I�O�1
District?
❑Year El No NEW RESIDENTIAL SUCH. SQ.FT.
I have mad Ik havNous materials apdorro me under Chapmr 6.95 of he CITY Ur wrEH I INU
California I Iealth&Safety Code,Secions 25505,25533 and 25534. 1 understand that
if the building does not curemly have a tenant that it is my«sPonxibility m unify the
occupant of the requirements which must be mel poor to issuance of a Cer ificam of
Occupancy.
Owner or authurizeJ.gem Date TOTAL: ISSUED BY:
OFFICE