28054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLEIA MECHANICI- I'LRMI'1'NO. 28054
a ^ O
APPLICATION/PERMIT PLUMBROJECTECENJ IFIL LSV! 4`.Ja
.BUILDINGDIVISION BUILDING 1'ROJEITI'IUF:N'1'IF'ICA'1'ION
ILANGADDRESS: 1 SANITARY NO. APPLICVUONSUBMITTAALL�DATE
III® � Q- /� ' p I.al'p �'� '1
QW P 'NAME: H E: - NTR DR'S NAME LIC NO: NIC CONTROLp
a 1. e
ter<CHI'I'ECIIiNGINEEK: LIC NO: ADDRESS: ❑
CONI'Ac'f: PHONE: r 13UILDING PERMIT'INI*O
QTY. ELECI'I2IC PERMIT FEF.
L/ LUMiy •C
PERMIT ISSUANCE ��+ BLDG P
!1LUM5.5.
LICENSED CONTRACTOR'S DECLARATION AI'PLIANC&S-RESIDENTIAL
pyry IherehyaffirmCENSEllCONTR CTORvisDECLCkper9(cammencin6with 'IL/
�00 Section 7")of Divison 3 ofthe Bronessind Professions Code,andmy licease isin PANELS
<,,F. full force Cis.effect. t /a7� _ _�
�<& License Class Lic.p IIP T0200 AMPS 9jay%y�`"��>{ 1
c,QN Date Conwaor 201-uIW AMPS
y FO=` ARCHITEC7PS DECLARATION OVER IOOIIAMPS SQ,EL FLOOR AREA S/SQ.FT.
pp underslund my plans,boll ba weJ as pumlc recood,
F y l-•ul SIGNS ELECTRICAL
'yy5 Licensed Professional
aWOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I'
Xowu 1 hereby uff n that I am exempt from the Contractor's License Law for the
at 3 a y following mason.(Section 7031.5,Business and Professions Code:Any city correctly TEMP.METER OR POLE INST.
which requires a permit to construct,ulmq improve,dennlish,orrepalr any suumum
f' }� poor to its issuance,also requires the applicant for such permit to file o signed statement POWER DEVICES
�1<pthat he is licensed profound to the provisions ofthe Contractor's License Loss(Chapter
9(ennnteneing with Seen-9000)nf Division 3 of the Huslnesennd Proficedrns endo) SWIMMING POOL ELECTRIC VALIDATION
y'^y
.,,hot he is eminin ierefrom and the basis for theailegd exemption.Anyviolanonof OUI1ETS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a p mount subjects the applicantmacivil pennhy ofle
�p oat mthnn Ove hundreif nllum($SOt). NEWRPSIDENTIALELEC112_SQ.PT.
thevor ,endeesomet,ormyemterdeduroffeed agesas (Sec.
compensiiess STORIES TYI'L'CONSTRUC'I'ION
a3— I mhewmk,end the The Conurn tactor is License awdoes Is I apply to tin,Business
nd Professions Cole:The Contractor License Law docs not apply m nn owner of
Property who builds or improves thereon,and who docs such work himselfonhrough his
employees,providedthar such improvements arenot inrenddoroffered forsale.If, OCC GROUP RES.UNITS
however,We huilding or improvement is sold within one yearofoundeion,tbrowner. ?. '
builder will have the burden of proving that he did not build or improve for purpose of
cale.l.
❑ I,mownerofthe propeny,am exewsively rnntricting with llc- dcmma t to QPY. „ PLUMBING PERMIT' FEE FLOOD ZONE ql'N
construct the project(Sec.TNG,Business and Professions Code)
The Co _snot pf:RMIT ISSUANCIi
License Law does not applyto an nwnesofpupenywho buil�:ut.
reo ,and
when Cammms Tm.uch pntjeas wil ttermranm(O license, C. It,
gL'TER-DRAIN&VENT-WATER PA
License law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. is mason ACK FLOW PROTECT.DEVICE SI L FEES
SAN]LARY 'Y N
Id1Owner Date DR $-FLOOR,ROOF,AREA,COND. RErn,sTp
`1 WORKHavcac Fl1r S T DECLARATION SCHOOLTAX Y N
II c❑eeracmiaffimvhmlmveaccrti0c of consent mself-ireure,ora ccnifmnmf RECIBFTtt
PIX'NR '-PER TRAP
Wmrs.11e employees
this eor enifid copy therwf(Sm.3g00,iab CJwhich PARK FEE Y N
m all employee's unJer this pe it. GAS-EA.SY Md INCA OUTLETS REC
Policy p BUILDING DIVISION SION PEES
Company GAS-EA.SYSTF. VER4 kA) PLANCHECK FEE
❑ CenifeA copy is hereby fumi mJ.
❑ CcnilieA copy is fled with the n;inspection division. GRHASEANDUSI'RI. SIE INTERCEPTOR GRADING FEE
CERTIFICATE OF EX MPIION FROM WORKERS' EASETRAP SOILS PEE
COMPENSA ON INSURANCE
(Thissemionnecd notMmmplerN thepennirisformalmdred lars($100) ER-SANITAR?-S1' MEA.200FT. ENERGY FER
c r Iaa)
I certify that in the p 1homencent the yuck forwI,i,h,hi,perm Issued,Ishan THR I IEATERW/VENUEECTR
ant employ any perum in any marmer solo to be erne su1T ma the Wm4fts PAID
Compcnmtion Lawsof California. Dam II WATER SYSTEMGREATING Dare Receipt
ZZ Applicant
NOTICE I'O APPLICANT:If,after making Nit CerLc Ex option,ybtt;hyT(I NISW RP.511)CNTIAL PLMR. SQ.FT. TOTAL:
a•+ r/] became subject the Worker's Compenortionpovisons of th rCde,yot�ir 11
L—� forthwith comply with such provisions or person shall he Jeea Imvoked. / BUILDING FEE
LkI Q CONSTRUCTION LENDING AGENCY � SEISMIC FIR;
� 'z I hereby affirm t lout them is u ransomed.,letkdlng agency for the performance of
U O the work for which this permit is iswd(Sec.309'ii Civ.C.) L: ' P,LECI'RIC FEE
Lendc/s Name 1 PLUMING FEE
0 U Lemt I reminrasa I QTY. MRCHANICAI.PERMIT'. PE8
1 c I age that I hove read this application and
ether the above infommtion ie
4 correct. lagree rocomply with ell city and county or di d vommwa relating to' PERMIT ISSUANCE MECHANICAL FEE
building cmutrudinn,and hereby authnrim o,rosentativ nv of tuts city w enteru'ri me CONSTRUCTION TAX
V Z alawementioned pmperty for inspection purposes. / ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the ty of CUpen gamer
Ilabiblice,jdgments.com,and expenses which may many way a 1tpilguinvtsair[City AIR HANDLING UNIT(TO 10,000CFM)
asequence ofthe granting of Nis pcmtit.
AIR HANDLING UNIT(OVER 10,0110 CPM)
Sigwtureof Applicunt/Commctor Date EXIIAUSTIIOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,015 BTU) Date Receipt#
Will the applicant or future buildingoccupant store or handle hazardous material HGTING UNIT(OVER 10(1,1100 BTU)
as dcrined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Senior 25532(.)
El Yes '1 o VENTILATION PAN(SINGLE RESID)
. Cy
Willtheupplieamo/rfuw_re huildingoocuput useerui memonleviw.v whichcmit BOILER-COW(31 IF OR 100,000 BTU) ISSUANCE DATE huarJws air mmvninents asdefend by the Bey Arte Air Quality ManagementP9AID
BOILER-COME(OVER 100.000 BTU)
Uigrin? �\ //''�� 1 t�
❑Yes D�arft NEW RESIDENTIAL MECII. SQ.FT. MAY i O 199q
1 have read he namrdoo..mmenels mcmdom ems under Chapter 6.95 of the V
Cailinnin IIdJ1h ffi Safdy Calc,Sections 255(15,25533 and 25534.I unJeadand tlon CITY
IFthe balding J m anenny na.•e a tenant.torn a is my reaponamuity m naify t Uh V'UrtH 1
ccupunt of h'ch must be ten poor to issuance of a ficote f
Occupier
Owner or tvhurizal age ISSUEDB
OFFICE