27378 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
� l flUI LO :-ELLL'FRICAL PERMI'TNO.CITY OF CUPERTINO PIG-MECHANICAL BUILDING DIVISION APPLICATION/PERma BUILDING PROJECT IDEN1FIC
27378_7J7O
BUILDDDRESS' SANITARY PIICTIOTNSSUBBBMMALDATE//fA^L,k / 19LOT0
PHONE: CONTRACTOR'S NAME: LICNO: N/C CONTROL#
C ITE INE : W dj(r` _ ADDRESS: ❑
CONTACT: CI`�JJ?21: HU
QTY, ELECTRIC PERMIT FEE
ELEC
/� QQ a aIIDINT PERMIT INFO
7J Q e / J • PERMIT ISSUANCE �.�. PB MECH
IC`'
LICENSED CON T'RACTOR'S DECLARATION AVPLIANCES-RESIDENTIAL i_il•
Thereby ff that l amlicemud under onsol'C'heter9mardamncin with JOB OESCRIPI'ION
0QWZ00 Ye provisi p ei
+a'U) Section7").f
andefDivision]of the Business and Professions Code,and my license is in PANELS
<ZU fail License
Cladeffea. UPT02MAMM
N<Zyt Licenu Glasse Conneaut
Qy Dme Cnmmcmr 201-1(100 AMPS
,Zi DD ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.IlOOR AREA 5/SQ.FT.
OZ l understand ed
dersd my plans shall he usas public record.
_q� SIGNS ELECTRICAL N�d� Licensed Professional
g y�WQ
OWNrR-HUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aU I hereby affirm rapt from the Contractors License law for the
fllowin rt o . Bnessamd Pmfessiom Code:Aaycit mcoumy TEMP.METER OR POLE INST.
0� which w" tN,improve.demolish,or repair any swqurc.orq a. an euplicaut forauch Permit file a signed statement POWER DEVICES
yl�<o shat Pa...uonc�provision afore ContraNWs Licenu Law(Chapter gWIMMINGPo LEfbC'IRI
a e 9(co, gwalt Section 7000)nf Division3ofthe Businessand Professions Code? VALUATION
yYj_y or that he emptthe.from and the basis for the alleged exempsion.Any violation of OUfLETS-
Ie2—ZQ Section 7031.5 by any applicamfor.Permit subjmtnhe applicant too civil pertalty of ITCI{FS-FIXTURES � �� /Q�
K�CO not more than five bundreddol Tom I15M. NEW IDENTIALELE VVV l•
5� ❑ 1,asownerefthepmpeny.ormyemploymswithwogesntheirsolecompansatioa. Q' STORIES TYPECONSTRUCTION
W will do the work.and the structure is not intended moffimed forsale(Sm.7044,Business VV
and Profess ns Cale:The Cmundo ea Licenu Wes does ON apply to an owner of
pmpnnywhobuildorimproves themon.andwhodoes such work himselforthmugh his OCC.GROUP RES.UND'S
ncmployms,Providedhat tach improvementsamom intendedor Offered for sale.If,
h wever,Ne huildingor improvement issoldwithinoneyeaofe mplesion,theowner- TOTAL:
builder will have the hur ler of proving that he did not build or improve for purpose of
❑ I,mownerofthepmpeny,amexclusivelycontmaingwithlicenedconl.d1.10 Q Y. P BIN I!RMIT IEE FLOOD ZONE AIN
o.moneN the project(Sec.7004,Business and Pmfersions Code:)The Cmarmur's
PERMIT ISS E
License lawdnesnm apply to un ownerofprotedy who buildorimpmvesthereon,and
whocnntmets forauch projects with acommoods)licensed pursuanuothe Conwcmr's
Licenu Low. ALTER-DRA &VENT-WATT: EA) FEE SUMMARY
❑ I um exempt under Sea ,B or PC for this reason NAC OW OTECf.DEVICE OUTSIDE NES
SANITARY Y N
Owner Dam RECIIIPF#
D INS'-I1, OP,Ak ,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby affirm thalhave ecenificae of continuo of-insert.Nacenificem of FIXTU .S-PER TRAP RECEIPT Is
Workers'Compensation lnsumnee or a certified copy thereof(Sec.3800.Lab C.)which PARK FEE Y_N
covers
all employee's under this Permit. GAS-EA., STEM-I IN 4OUTLEfS REGI?IPI'#
Policy BUILDING DIVISION s
Company GAS-EA.SYS VER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Codified copy is(Bell with the city inspection division. GRFASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FL's
COMPENSATION INSURANCE.
(This section mcedmot be completed ifthe Permit is Ferran hundred dollars DIW) SEWER-SANITARY-STORM E.A.200FT. ENERGY ILL
or less.)
I cenify that in the performance of the work for which this Permit is issued,l shall WATER HEATER W/VENT/RLECfR
nos employ any person in way manner so ss to laminate subject sec the Worker' PAID
Compensation lawsof Califomia. Dae WATER SYSTEM/TREATING Date Receipt#
O Z Applicam
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESI DENTIAL PLM#. SQ,PT. TOTAL:
(•" (q become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such Provisions or this permit shall In,deemed Invoked, BUILDING FEE f
per, CONSTRUCTION LENDING AGENCY SEISMIC IEE
Z
1 hereby affern that them is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) T ttj. ELECTRIC FEE
Lcndera Name
Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L7aI cenify that I have seed this application and state that the above infowalion is MECHANICALFEB
coral. I agme m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
FLn building conswaion,and hereby authorize mpresenmtivesa(this city tomterupo 'he CONSTRUCTION TAX
(, above-mentioned property fns inspection punto... ALTER OR ADD TO MECIi.
( e) teem ,indemnify and keep hmmlesa the City of Capcnino against
ba, e,j dgments.co. endo rteswhichmaymanywaysecmeagaintraid City AIR HANDLING UNIT(T010,000CFM)
in urn dihegrat Is his Premie 1 ft 4o 1 AIR HANDLING UNIT(OVER IO,IX)(I CFM)
'ignam of ApplicantlCnnt q ct r Date EXHAUST HOOD(W/DUC
PAID
HATH DOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the apPlicmn or future building occupant pore or handle hazardous material BEATING UNIT(OVER 100,(X10 BTU) TOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
k fps
Cale,Section 25532(n)R
❑Ycs ❑No VENTILATION FAN(SINGLE RESID)
Will rM1cupplicum nrfwure M1uildingoccnpumuse equipmenmrdeviceswhichemit
BOILER-COMP CIHP OR 100,000 BTU) ISSUANCE DATE
hazNdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distri !
• x'
PA
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. W 0
I have mad the hazardous materials requirements under Chapter 6.95 of the
California d &Solely Cale,Sections 25505,25533 and 25534. l understand that
�e�
iftebuildingdoes rad lyhaveamismyrtebiliq0illy the
O
mutant ofthe requirements which man bemet prionm issijancofo
Crnificme of Cl/Y f
Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE