27292 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-Ell MECHANICAL
ECHA IA. PERMIT'NO.
APPLICATION/PERMIT PING PROJECIADENI IFICA
BUILDING DIVISION BUILDING PROJKCI'IDENTIFICATION 27292
BUILDING ADDRESS: N I SANITARY NO. 1 APPLICATION SUBMITTAL DATE
O �/\8tr'I/ 1 kLtI UNIT'# LOTH �� '`
OWNERS NAME: rs0 mss. PfiO - .0 7C TR CTQR' B: ( �Q LCNO�O NIC CONTROL# -1
•ARCUI'IECT/ENGINEIiR: -�sLTL LIC � A1107�5�{NFO' N� -$ ❑ .
CONTACT: PHONE: / BUILDING PERMITINFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE 0 IJ�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL 108 DESCRIPTION
�-s\
Qo:z Ihereby affirm that l sm licensed under provisionsofCluptm9(commencing with
iU0W0 Section70W)of Divi,ion3of the Business and Professions Code,and my limn.is in PANELS
yaa U{-. full force and effect/ 2�s
"6t License Class e� Lic.p� UP T02o0 AMPS
m 4 LLL Dc,in¢ Contrumor 201-1 WO AMPS ���7�Y1
ZOs`"ir/4. ARCHITECTS DE IARATION OVER Ig10 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1 understand my plans shall be used u public records.
F f:C W SIGNS ELECTRICAL
Q f� Licensed Professional
WKw OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
RE, I hereby afloat that I don exempt from the Conuacmrs License Law for the
W3V.y following mason(Section 7071.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
'V10 which requires o permit in construct,alter,improve,demolish,or repair any structure
fa1aE Inrr to its issuance,also requires the applicant forsuch permit to file a signed statement POWER DEVICES
y)cJJ O that he is licensed pursuant to the provisions of the Comma fur's License law(Chapter
da mm 9(commencin with Section 7")of Division Sof the Business and Professions Cade SWIMMING POOL ELECTRIC
�x4otr- 8'+' 1 TRIC VALUATION
W—w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWRCHTS-FlXTDRFS
F Z a Section 7031.5 by my applicant for a pmt
cit subjects Ne applican
no a civil pnulty of
t more than five hundred dollars(1508). NEW RFSIDENTIAI.ELEGIR _SQ.FT.
n❑ I,asowncrrfthe ro y p y g pens"
p perty,e is em to cawiNwa arsale(Se.cam tion, STORIES TYPE CONSTRUCTION
will dothewonsCde: structure isnot n's License
ffionid wdoes of apply to an
and Professions Cade:She Conthereons License Lew does not apply lf nn owner of
propertywhoes,dsorimprovesthereon,andwhodocssuchwork hiroseIfedthroughhe
own employeesilding or ded such improvement
earrof doroEaeJ outsidetheow.IL OCC.GROUP RFS.UNITS
howevmilde,gThe buildhebudeprovemmtis midhe within mid.,i prove far theowner TOT
builder will have the bunirn of proving that he did not amid.,improve fm puepose of
❑ I,.ownenmrthe pmpcny,amexdusivelycom.cting wiN licensed cnntrcmrsm QTY. PLUMBING PERMI'iFf: FLOOD ZONE "N
amasser he projeo(Sec.70,14,Business and Professions Codc:)The Cmummusre PERMIT ISSUANCIi
License Law does not apply manomora(pmperty whobuildsorimproves thereon,and
whoembacts for such projects with acontrctor(s)licensed pursumuothe Contramrs ALTER-DRAIN&VLNT-
License Law. W 'R(HA) - FEE SUMMARY
❑ I am exempt under Sco ,B R P C for this sawn BACK FLOW PROTECT.D ICE OU ID•
SANITARY Y N
Owner Date RECHIM#
WORKMAN COMPENSATION DECLARATION
DRAINS-FLOOR,ROO ,AREA,GOND. SCHOOLTAX Y N
• I hereby affirm that l have a cenificatc ofcoment to self-insure,ora certificate of FIXTURES.PER 1' RECEIPT'#
xknACompensllion Insurana
ce mcenified pythereuf(Sec.3800,Lab C.)which I PARK FEF. Y N_
covers allemploye`s ande"hla peeni`A/a0A3073 GAS-PA.SY M-1 INC.40 RECEIPT
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYBTF.M-OVER 4(E PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Ceniried copy is fled with the city inspection division. GREASEnNDUSI STFI [RCC GRADING FEE
CERTIFICATE OF EXEMPTION I-MOM WORKERS' GRHASETRAP SOILS IEE
COMPENSATION INSURANCE.
(This section need am be,completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-S F I'Mi T. ENERGY FEF;
or less.)
I certifythat inthe perfxecomeeofthe work for which Nis permit is houW.l shill WATER HEATER WNEWIELECIf
not employ any person in any manner so as to become subject to the Workers PAID
Compvmatimusesof Califomia. Date WATER SYSTIE"If RHATING Data Raeipt#
0 7r Appliemt
z NOTICE TO APPLICANT:If,after making lhis Ccnificateof Excmptim, ,should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
r V] become sidecar, the Workers Compenxationpowisions of the Labor Cocayuu must
�i forthwith comply with such provisions or this permit shall be deemed revoked BUILDING FEE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency fm Ne performance of TOTAL: ELECTRIC ME
O the work for which this Permit is issued(Sec.7097,Civ.CJ
4s Under',Name
Lender's Address Q'iV, MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is
CWa come,.l agree m comply with all city and county ordinances and state is.relating to PERMIT ISSUANCEMECHANICAL FEE
pct buildingconstruction,and hereby authonco representatives ofthis city memup
ran the saw
U ,Z. above-mentioned property fm inspection purposes, ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)"gram save,indemnify had kap humlies to City of Cupertino against
liabilitieajudgneents.costsandexpenses which may in any way acu.eegaiaB said City AIR HANDLING UNIT(TO 10.000 CTM)
in consequence of the farming of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of A,hrnt/Cmanaltr Date EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE / HEATING UNIT(TO 100,000 BTU) 752r, Date Receipt#
Will the applicant or future building acupset acre or handle harardous mntenal
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER DR."BTI) WTAI.:
Cade,Sall 25532(x)?
ID Yes J19 Na
VENTILATION VAN(SINGLE RESI O)
❑
BOILER-COMP(31IP OR 1 UO,OW B'I'Of ISSUANCE:DATE
Will the hpplicunun future building acupmt use equipm<m or devices which emit ,
• mono ous air contaminants as defined by the Hay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distncr!
❑Yes KNo NEW RESIDENTIAL MECH.—SQ,SQ.FT. l.#
I have mad the hdmNahs matennls 5505.25533 under Chapter 0.95 nd the Yfl �k
Califomia Health&Sel'dy Code,Sections 233(15,25573 and 25534. Iundersland that 7 (.,]}IJ1.`✓J{Irx—lrry/
if the building docs not currently have a count,that it is my responsibility to notify the vat
enpant of the requirements which must be met prior to issuance of a Certificate of 1
el
Owner or auNonred age. Date L: ISSUED BY: I INV
OFFICE a