28373 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL MUBNG-MECH MECHICALANICAL PERMIT NO.
APPLICATION/PERMIT vING PRNC.-MEDENTICAL
BUILDING DIVISION II1111.DING PROJECT IDENTIFICATION 28373
BUILDING ADDRESS: - SANITARY NO. APPLIGY1 ION SUBMJ]I A.DATE:
/Oro3 S�/ool �j(� UNIT# 1.01,# 5 w7/
OWN"
'�RS NAM(JC�' PHONE: CONT Cl'O CS NAME: - LICON/C CONi'ROL#
RCIIITCCf/E�+GlNlili LIC NO: ADDRESS:
4 t/JSO G✓a1 f- Tire C°• sy/p
CONTACT: PHONE:
` QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELF.0 PLUMB MUCH
PERMI'I'ISSUANCE ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDLNTIAI.
IM1ereb dDivisio l3 ofth Buantler fnsCrer and mmenbin th 1 DESCRIPTION
O tKZ Ya provisinmo p gwi
to 00 fusioneandefcivision3nf the Business and Professions Code,and my license is in ppryp�
<Z� Licullense
forcnse Clndeffcct.
GL License Class Lie.p UP T02f1(1AMPS
y�y Dam Cmumater 201-IOW AMPS
,ZONA ARCHITECTS DECLARATION OVER 1(100 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall be used as public records.
P m ul SIGNS EI.IiC'I'RICAL
q'y ')j I.Ittmed Professional
S WU OWNER-BUILDER DECLARATION SPECIAL CIRCUTEMISC.
O p,F 1 hereby affimt that I roes exempt brutish Commctors License law for the
F 40m following reamr.(Seen,.7031.5,Business and Professiooa Code:Any cityorcnu.ty TEMP.METER OR POLL INST. /
which rcquves a permit to cunstmct,alter,improve,demalish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES
pj C G p that he is licensed pursuant n the provisions of the Cnnlmcom s License Law(Chapter
9(conimencing with Section 7000)of Division 3 of he Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that lie is exempt thercfmnt and the basis for the alleged exemption.Anyvialntlon of q OU'11.17'1:5-SWITCHES-FIXTIIRI:S
Sadism 7031.5 byany applic�nt for. mail,chjems the applicant to a civil penalty of i
22aothan five hundred d.11...(SSW).
1 Wim
nmre❑1 ,asowuroflhepnsperty,ormyemploycaswithwuge mtheirsolecompcnmtiNEW RISIUP .NTIAL ELELTR _SQ.FT.an, S TYPECONSTRUCTTON
d3— will clothe work,and the structure is not intended material Fortune(Sm. Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whobuildsorimprovesthearch.and whodoessuch work himselfanho ughbis
employees,provided that such impvccntsnot mandedaffered mrsale.If. O .G UP RIiS.UNITS
hommemm
wever,the building orimproverm nt is sold within one yeurofwmpletioq tbeowner.
builder will have the harden at provingthat hedid not build moreover forpur,ascof T L'
a.).
❑ I,as ownensfthe prupcny,nm exclusively comrncting with licensed contractors to QTY. PLUMBINGPERMIT PTF. Iq,000 ZON' qPN
construct the pmjcct(Sec.70H4,Business and Professions Code:)The Contractor's
License Lowduesamit,ply to anownerofpropertywht buildammaprovex thereon,said PERMIT ISSUANCE
whocontmcts forsuch projects with a eontzactiona)licensed pursuanumhe Contrutars ALTER-DRAIN&VENT-WAT'IiR(EA)
License law. FEE SUMMARY
❑ 1 am exempt undo See. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE H.,
SANITARY YN_
Owner Dane RECEIFI'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPLcate ofIONent it)DECLARATION SC0001.TAX Y N
o ers Coyaffirm tocol Insuraave a nce
o cents ofcansennoaef(insurs,or.m.3810.Leb C.)e hiof RECF;IPTM
Wahers Compensmion Insurance racenifed copy thereof(Se<.3g00.lab C.)which FIXTURIiS-PF.R TRAP PARK FEE YN
v coven all employ$e�5 alyiSpermil. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPI'M
policy !! BUILDING DIVISION FEES
Campus. ^` te. GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK THE
❑ Certified copy ishereby famished.
❑ Certified copy is fled with the city imspenion division. GRPASIVINDUSI'RL WASTE INTBRCEPI'OR GRADING FFH
CER'I'IFICA1E OF EXEMP1 ION FROM WORKERS' GREASL'I'RAP SOILS FEE
COMPENSATION INSURANCE
(This sdadon need not be completed ifthe permit is fomne hundred dollars($IW) SEWP.R-SANITARY-STORM EA.2000. ENERGY FET?
or Iesa.)
I certify that in the performance oftoe work for which this permit is named,I shall WATER HEATER W/VENT/ELF:CfR
.it employ any person in any manner so as to become subject to the WorkersPAID
Catniatanion Lawsof Celifomie. Date WATER SYSIEMITRF.ATING pate Rueiptp
0 z Applicant
NOTICE TO APPLICANT:ILafter makin,mis Cenificme of Exemptimi,rou should NEW RESIDENTIAL PLMB. SQ.FT. TOTALi
became subject to the Workers Compensation provisions if the Lahm Code,you most
limhwitb comply with sublt provisions or this permit Jml l he deemed revoked. BUILDING FRE
0. Q CONST RUCTION LENDING AGENCY SEISMICFEE
7 z 1 hereby affirm that there is a construction lending agency for the performanw of
V!Q the work for which this Permit is issued(Su.3097,Civ,C.) TOTAL: ELECTRIC ITE
Lenders Name PLUMBING FRE
I
1<ndAddress QTY. MECHANICAL PERMIT PEE
V certify that 1 haw..,],his application unA start that the above infomiminn is
F4 buildinglagrecmcoilad withaymnla and repreamaivirmsod statelows rdntingm PERMIT ISSUANCE MECHANICAL PRE
's tini,ingcndonsedioqurM1arinspmhonpreprcsentmives of this citymenmruponthe CONSI'RULTIONTAX
V z above-mentioned property save,indemnify and purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify and keep harmless theCityof Cupertino against
Iiacanaresjutleofthecosts
graving cxpenseermit. may in any way ucmeagainq sail City AIR HANDLING UNIT(TO IO,UXI CPM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.(X111 CFM)
Signal are of Applicunt/Contrador Dam EXIIAUS'1'1100D(W/DUC) PAID
'\ HAZARDOUS MATERIALS DISCLOSURE IWATING UNIT(TO 100,000 BT U) Date Regia#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW,tXq BTU) r✓�/ TOl L:
as defnW by the Consonant Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section x77
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Yes
SNC9 DATE
Wilhhe epplicantnrfmurcbuildingoecupanmseequipmenmrdevices which etrdt BOILIiR-COMP(]HP OR 100,iKK1BTU)
amrdous air contaminants as defined by the Buy Arca Air Quality Management
PCistricl? BOILER-CDMP(OVER 1(NI,(NlfBTU)❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT.I have lead the hazardous materials requ ncracab under Chapter 6.95 of the
25505.25533
V
alifomia Hemth&Safety Gale,Sections 25505,25533 and 25534. I understand that
ifthebuildingdoesnotc con,
atenant,that it is Issuance of.
tenotifythe
occupant of the
req cots which most}mc5�rcior to issuance of a Certificate of
Owmam uthorized agent /��� Date 'TOTAL: ISSUED BY:
OFFICE