28299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO H ILIHNG-ItLP.0 IHICAL PERMI'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28299 O (] (�
BUILDING PROJECT IIIF,NTIF[CA'I']ON L O J .7
BUILDING ADDRESS: n SANITARY NO. AI'PLICA'HONSUBMI'fl'ALDNIE
1` 1/s1��
`I)NIT# LOTH �6
RS NAME CJ 8P I ii: CONTRAC/T�OR�'S NAME: LIC NO: N/C COM'ROL#
r K/
IfITE GINEIiR: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
/���/) � 1y.) j��r /Iy' QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ICJ V��/( s /O�� PCRMITISSUANCE DLgG ELECT11 El 11
PLUMB MF.CH
LICENSED CONTRACfOR'S DECLARATION \ITR
pat Iberehyaf an bre l am licensed ande,provisiomnfainder9(commencingwith APPLIANCES-R[SIDENTIAL ^__ JO'B DESCRIPTION
+1100 Section 7(tomol'Divisiad 3 of the Bmice.otmd Professions CWe,ond my license is in PANELS •Vl . l <�
es dU lull force and effect. 111/dill �
It<.....-ZW License Class Lia# UPT02WAMPS
y<y Date Contractor 2M-1006 AMPS
Z0ARCI NI'ECTS D14CLARATION OVER iII(IIIAMPS SQ.FL FLOOR AREA S/SQ.FT.
O Z o,❑ 1 understand my plans Shull he used as Public rcmNs.
F m t W SIGNS ELECTRICAL
k Licedaed Parm.iomd "n,
ly OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaF I hereby affirm that I am exempt from she Commands License Law for the
W3 a wa following mumn.(Section 7031.5,Business and Pmfeasious Cale:Any city ser County TEMP.METER OR POLE MST.
g,O.J which requires a pemtit to connnmt,aper,Improve,demolish.or repair any structure k
},2 priorm its iem...alao requires the applicant for such permiuo file a signed statement POWER DEVICES It
O that he is licensed pursuant to the provisions of the Contmctols License Law(Chapter
ef' 9(commencing with Section 700dof Division Jofthe Business unit profession,Cale) SWIMMING POOL ELECTRIC VALUATION
[V_
so nr that he is exempt therefromunl the basis l'onheallegW exemption.Anyviolatim of
CZQ Section 7031.5 by any applicant for a permit subjects the applicant tp u civil penalty of OUTLETS-SWITCI HS-FIXTURES
tmore than five hundred dollars(ESool. NEWRFSIDENTIAl RLECTRS .FT.
W ro n❑ I,asnwneroftheprolcny,ormyemployceawilhwugesustheirsolecompensatinn, Q STORIES TYPE CONS'1'RUCTION
n ofd l do the work,and the Structure is not intended or offered for sale(SeC.J(1m,Business
and Professions Code:The Comtmnors License law does not apply or an owner of
property who builds or improves thereon,and who does such work himselforthrough his ACC.GROUP RES.UNITS
own employees,provided that such improvadents ire not intended or offered for sale,If.
however,the building or improvement is sold within one yevofth mpleuon,the owner- TOTAL:
builder will have the burden of proving that he did rim build build or improve for purpose of
Ie.).
❑ I,nnwncrofthe pmmny,um excluaivelycommcting with licensed convacmrs to QTY. PLUMBI PEI I FEE FLOOD ZONE APN
construct the moject(Sec.1tWi,Business add Profess ons Cade:)The Commcmr e
Lumselawdoesnot applymanownerofproperry,who builds crimprovesthereon,and PERMIT ISSUANCE
whocdnmacis for such projects with a Contmeror(s)licensed pursuutuo the Contractor's ALTER VENT-WATER FA
License Law. ( ) FEE SUMMARY
(3 I amexempt under Sec. ,B&P C fit Ihix reason BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner - Dom RF.CEI #
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Fhereby affirm that lhave
rance or ifiwm of coop, une.f(ier.m,or3910,Lah C.)c m ofwhich FIXTURES-PER TRAP [CE p
Worker'Campenee', nder thinoearaeeniliod copy theeo((Sea.3g00,Lob CJ which PARK II3B N ea
coses ell employeds under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS :I�#
Policy# BPBj)lqaISION FS
Company GAS-EA.SYSTEM OVER TSG PLANCHEC
❑ Cenifiel Copy it hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADI F
CERTIFICATF.OF EXEMPTION FROM WORKERS' GREASETRAP gpB,
COMPENSATION INSURANCE
This rection need not bechandeted ifthe pemtit is fsrone hundreddollars(5100 SEWER-SANITARY-STO EA.200FT. ENE
unless.)
Icenifythat idther per-om®nce of the work for which this Permit is issued,I shall WATER H RATER W/VEN'OEL.'
not employ any Person in any manner so as to become subject to the Workers' PAID
Z Compensationlawsof Califomia. Dam WATER SYSTEM %s7 G am Receiptp
Applicant
Z NOI'TCETO APPLICANT:If,uBer making this Certificate mExemption,you should NEWRESIDFPTI .P, SQ.FT. TOTAL:
t+ � become subject o the Worker's Compensation provision thither Labor Cade,you most
Ki > forthwith comply with such provisions or this permit shall h deemed mused. 1A M BUILD G FEE
aQ CONSTRUCTION LENDING AGENCY _ SEIS CI'EF: Is
VZ Thereby affirm thauhere is acnnawnion lending agency for the perfthmmnce of
0 the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELF. RIC FEE
D-, aLender's Name
C) Lender's Address QTY. MECHANICAL PERMIT FEE PLUNkING FEE
1 certify that 1 have read this application and scam that the above information is
correct.l agree to comply with all city and county ordinances and state laws rclmingto PERMIT ISSUANCE MECHANI FT.E.
fn building construction,and hereby nmhorive mitescnmtivcs ofthis city to enter uponthe CONSTRUCf10 A%
V z 4�N,��zcJ� ., y forinspection purynses. ALTER OR ADD TO MF.CH.,indemnifyandkeeph City of tido againt
stsxpenmsM1i anywa a gainst said City AIR HANDLING UNIT(TO Io,(XI CFM)
a, thfthispe
AIR HANDLING UNIT(OVER 10.000 CTM)
ignu[re of Applicum/Contractor Date IiXI1AUST HOOD(W/DUCT')
PAID
HAZARDOUS MA DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Ra t#
Will the applicant or furore boldin thiant store or handle hazardous material HEATING UNIT(OVER 100,0(X1 RTU) T Al.:
as donned by the Cupertino Municipal Code,Chapter 9.12,and the Ilemb and Safety
Calc,Section 25532(a)'!
11 Yes ❑No ILVENTATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 103.0 AI BTU) ISSUANCE DA'
Will the applicant future building occupmt useequipmem Or Jeviceswhichemit 11�� pp
hasandims air contaminants as defined by the Bay Area AU Quality Management BOILER-COMP(OVER 100,000 BTU) Ili q 0
DHmC,r
❑Yes ❑No NRW RESIDENTIAL MRC I. SQ.FT. (�
I have mad the harnNous materials mquircments under Chapter 6.95 of the AUS 02 1995
oCalifornia Health&Safe,Code,Sections 25585,25533 and 25534. 1 understand that 1r�sfJ7�sJ7y�s�/0�®
ccupandre ofbuilding does notcurrently have a must
tha et pons my reuance of a Ce notify the CIT Y 1;`\.r-C�' `j/
occupant of the requirements which must be ma prior m issuance of a Certificate of b („J/- (yUrO� I
Occupancy.
Owner or amhoriaed agent Date 'TOTAL: ISSUED BY:
OFFICE