27774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO n IL 1 .- IKICAL PERMITNO.
APPLICATION/PERMIT PI•UMNING-MECHANICAL /'� q
BUILDING DIVISION BUILDING PROJECTIB F G LI
BUILDINGADDR_ _ Egg: SANITARY NO. APPLICATION SUBMITTAL DATE
-g`K—/'1�1f✓tea-�`f`�'1' ZLW UNIT# LO'N
OW SNAME; PHONE: ANIPINTRACI'OR'S NAME: LIC NO:
II N/C CONTROL
RC IITiCT/FNGINFF.R:
LIC NY, ODRPSg: ///-1 El� 1
CONTACT: A PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/ C zO o PERMIT ISSUANCE ELCC P UME MECH
LICENSED CONTRACTOR'S DECLARATIONpppL1ANCE5-RESIDENTIAL JOB DFSCR ION
C 7 1 hereby offnn that 1 am licensed underprovisimnsofChapar9(commencing with
00 Section 7001 Downs 3 of the Business and Professions Cole,and my license is in PANELS
aZ fullfsee ad Clies ea. UPT02WAMPS
Q License Cass Lic.#
Qy Date Contmnra 201-11100 AMPS
t~y ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.ET.
OZ-0
rn OVER 1000 AMPS
02._ 1 understand my plans shell M dismiss public raoNs. ���� ��
SIGNS ELECTRICAL.
Licensed Professional � L �
Syd a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. KW
W4x U 1 hereby affirm that 1 am exempt from the Columbus License Law for the
ts13 O y following mason.(Seen.7031.5,Business and Professions Code:Any city or county TEMP.MITER OR POLE INST.
�rn5 which requires a permit to construct,alter,improve,demolish,of rcpalr any structure
}� pdnmoits issaancq also requites the vpplicent forauch permiuo fleasigned satemrnt POWER DEVICES
flat he is licensed pars and to the provisions of the Cooteactors License Law(Chapter
aao� 9(mancr acing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
aFa
orthat7031. by exempt
yappom and for a the basPermit subaasegeJexempromiton nylparraon of OUTLETS-SWITCHES-FIXTURES
Z,Y not mnetore thn ye hundred
dollrs($50rmit subjects the epplicanuovcivil penalty of L4J L
not mLinownfivehundmdrty.ors(SSW). NEW RISIDENTIALELECTR _SQ,FT.
❑ I,osownernl Nepropcny.ormyemployeaswithwagcsesthcirsolecompetuation, STORIES TYPECONS RUCTION
23� will dcba.mik,and theswence isnot intcndistmiffered farsale(See.701 Business �y
and Professions Codw The Cnmmctnr's License Law does not apply to an owner ofoss 15 �1
property whobuildsofimprovesthcaon,and whodeessuch work himselforthmugh his
wn empinyees.pmvideJ that such improvements urcnotimendeJoraflbredforssle.If. OCC.GROUP RBS.UNITS
however,the buildingorimproommt issold within yearofcompletion,theowner-
budderwillhare theburdrnofprovinguhm c w.-Til not ildorimprovefor puryose of
vale).
❑ Lasownerof"' pmy,ame ly commnQTY. PLUMBING PERMIT PEE ROOD ZONE APN
construct the project(Sec.RW4 usineas and Professn COJeq The Comrecme's PERMIT ISSUANCE
License lrwdmmot apply
ownerof property whobad Ni. mimpmves Ncrcon,and
whomillo,shnsuch p 'ctswithuconuector(s)licenseApu uanttothe Cmaractras PETER-GRAIN&VENT-WATf:R(FA)
License Law. FEE SUMMARY
❑ 1 em use under Scc. ,B&P C far this reason BACK FLOW PROTECT.DEVICE SANITARY Y E N
Own Data aRECCIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORK MAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ hereby affirm thm lhaveecenificate of conxnna self-insurt.uracenificaanf I, - RECEIPT is
Work tx'Cnmpenamion lnsumnccorviceniEdeat�.t)tererrnf(Sce.38M, .ab C.)which TXTURES-PER TRAP PARK FEE
covers ill employee's undo Nis pemtit. L/ GAS-BA.SYSTEM-IINCAOUTLEfS Imp
Poli, \ BUILD 10 ES
Company GAS.P.A.SYSTEM-OVER 4IRA) PLANCHECK FEE
❑ Cleifieimpyishereby is
❑ Certified copy is fled wi `' inspection division. GRFASFJBJDUSTRL WASTE INTERCEPTOR tINERGY
DING FE
CERTIFICA A EX MPI70N FROM WORKERS' GREASETRAP S
is COMP SA ON INSURA�CE
(This section nretl nm be cote Ic dif Ore permit,is fnrone hundred Jollwe(81(X11 513WfiR-SANITARY-STORM EA.2(#IFT. F
or Ie(
I renifythai in th performance of Ne work sLr which Nie permit ie isaueJ,Isholl WATER HEATER W/VENI'/F.LECTR
oat empty any pisom in any manner so.11.humor, subject a the Works.' PAID
Compensation Lawsof lifomia. Date WATER SYST3M/I'RFATING Dore c tN
O Z Applicant
O NOTICE TO AP PLICA 1(aftermakin-Nis Cenificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. OTAL:
� becnmesuhjecnathe Work 'e Compensation pmvsnne of the hnMr CnAe,you must t.
t� 7 forthwith comply with such u tons or this pcourtlshut]bedears!reyo BUILDING
UJ Q CONSTR rCTION LENDING AGENCY SEISMIC
Vz Iherchy affirm Nunh<reis mourectlonlendingagemcyfon fora ELE CE
O the work for which this permit is issued(Sec.3097,Civ.C.) �,
Lenders Nume
F Lender's Address QTY. MECHANICALPERMIT E'ER P FEE/39
W 1 cenlfy,that I have read this application end Ne abo anon is ME A AL .E
correct,Iagrce m comply withal)city and mm�tyo eaA sora ws relatioff PERMIT'ISSUANCP.
�^ building constmetion,and hereby authofiu rcprcummty es Niscirytoenterupon Ne CONSTRUCT' NTAX
U Z above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
09
liahit ies,juit ts,costs and expenses which may in my way acctueagainst said City AIR HANDLING UNIT(TO 10,000 CFM) �+
ip cou cyr sof thf,�runting of this permit.
_ AIR HANDLING UNIT(OVER 10,000,CFM) if
Signature of ApplicvnVCommctor w Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HPATINO UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant of future building occupant store or handle hamishrus material 111iATING UNIT'(OVIiR 100.000 111 U)
OT
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sati O 255326d? E)No VENTILATION IAN(SINGLE RESID)
UANCE ATE
Will the applicemorfuwre hm BOILER-COME 3HP OR 100,000 BTT) PIA
uildingoccupant useequipmeordevices which emit �V � G�
hazardous air contaminants v dcfned by the Bay Aum Air Quality Management BOILER.COMP(OVER 100.00)BTU) [J
District? INN
❑Yes ❑No NEW RESIDEMf1AL MECH. SQ.ITH
. /F 1��C
oil 1 have read the hazarme
hazardous materials requirements under Chapter 6.95 of the ay
California llealN k Safety Code,Senium 25505,25533 and 25534.1 understand Nat r(7h LUha h
if the building does nut curzeutly have n teoam,that it is my respomibility m notify the
rnci pout of the requirements which roan be met prior to issuance of a Certificate of lINU
ncy.
Owner
Owner or amhoriuJ agent Dore T � ISSUED BY:�\/I
OFFICE