27029APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOmr.°;NU-tT ,
BUILDING DIVISION APPLICATION/PERMIT PI,UMRINO-MECHANICAL.
BUILDING: FROBB(T IDEN'i'IPICATION
PERM] 'rNO.
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Iil11LDING DDS /5 IIw. %� UNIT# Tp
SANITARY NO.
APPLICAATIISONNN SSUBMMICIALLL DATE
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ADDREtS
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CONT PHONE:
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QTY y . r g'ELEjCTRIC PHRM1,7'z FEE
-BUILDING PERMIT INFO
BLDG ELECT PLUMB 'CH
PERMIT ISSUANCE
3 �JI �
❑ ❑ ❑
LICI'N D CONTRACTOR'S DECIARAt10N
hembyaffimn that I am licensedunder provisionsol'Chapter9(commenciagwith
APPLIANCES - RESIDENTIAL
10B DESCRIPTION
Scat In 7000) 'If iv oa 3 mine Heoness and Professions Coal and my license ie in
fillfnernod fetmst
PANELS
rn s -
',Illy /IV
Licenx Class '� I.ic.p
UPTO200AMPS
—)I/f
Dam Commctor
201-Iqp AMPS
ARCHITECTS DECLA 0
Lader t d my plans shall be used as public reenrds.
OVER 1000 AMPS
S .IT. FLOOR ARf:A
$/SQ.fT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
ran
SPECIAL CIRCUIT/MISC.
I I exempt from
n. ient(Se that 1 ton exempt from the Contractors Law for the
ebymason.
'TEMP. METER OR POLE MST.
C's e: Any
following mason. (Sita. 7031.5, Business and Pmfemionx Cade: Any city or county
ng
which require'. pemso re consweL aheq improve. Demolish, nr repair any swctum
Theapplicantfor permits,Lifile nse statement
primroiNiasmed
POWER DEVICES
purmnttotth Co LaO
that he is.cin, licensed S.fi. theprovisionsofthe Contractor, License Law(5C.,
9(commencing with Sccdon 70000 of Divixion3oftbe Businesaand Profesam Cod
SWIMMING POOL ELECTRIC
�/g VAL ATION
or that he is exempt @crefrom and the haste for the -(legal mptinn. Any vinleti
Secti.n?03L$by any upplic lli.upermitsubjenethe ap'nnftati6vilpenm of
ZS U
OUTLETS.SWITCHES - FIXTURES
not morethan Bve hundred dollars ($500).
❑ Lasosocrofthepropedy,ormyemploye it so ei'm com p;
aces
NE•W RESIDENTIAL ELECTR _SQ. FT.
STORIES al fj
)TYPHCONS'I'RUCTION
will Jn the wnrk,and the structure is nosimm�Je n m mle(Sek.)Q4], BBy(i est
end Prnfutdams Cale: The Commemr's Lice s a nal eppl (wrier of
property who builEmimproves theme.,and ssuchworkhi selfort ughhis
hoemployees,pmvided that sudmimp amen' Jedofalifered forsele. IL
wever, the hnildingorimpro e I itbin nc seem far lesion, theowner-
builder will have the burden of v set he did no Ido prove for purposeaf
O Pa .S
! •�� [Jh
µE10. UNITS
- 'TOTAL:
Q I-' PLUMBING PERMIT. FEE
sale.)_
❑ I,asowneroftheproperty.um naivecontracting with licensed commetem to
/ r .
iq.GOOZO fll
'Ida APN
instruct the project (Sec. 9044, Bu cas and Professions Code:) The Contractor's
License Lawdoss not opplyto an ownerof property who builds or improves T immi,anJ
PERMIT ISSUANCE
whoconlmetformat pmjectx with a conrecomad demand passional tolhe Cinamcsnr's
License Law.('
ALTER-DRAIN&VENT-WATER (EA)
FEE SUMN
❑ 1 am exempt under Sec. , B & P C far this reason
BACK FLOW PROTECT. DEVICE
NY � T&
SANITARY N
RECEIPT#
Owner DemDRAINg�FLOOR,ROOP.
AREA, COND.
WORKMAN COMPENSAT[ON DECLARATION
❑ Iherebyaffirm that l have acenifirmeofconsemm self-insum,oracertilicme of
Workers Compcnvtion larsuranceorac ifi ticopy hereof(S .Jg(p, Lab CJ which
SCHOOL TAX YN
RECIi1PTq
FIXTURES PER TRAP
PARK FEE YN
GAS - EA. SYSTEM -I INC. 4 OUTLETS
covers all employe,
Policy rt (/
RECFIPT#
BUILDING DIVISION FEES
Company
❑ Cenifiedcopyish erhyfumished. V9
GAS - EA. SYSTEM -OVER 4BEA)
PLANCHECK FEE
GREASE(INDUS'1'RL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 20l
ENERGY ME
("is section ared.ot be completed ifthe permit is for one hundred dollars($100)
or less.)
WATER BEATER W/VENT/ELECIR
I certify That in the performance of the work for which This permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker,
PAID
Compensation Luwsof Califomie. Date
Applicant
WATER SYSTEMfGREATING
Date Receipt#
NO3'ICETO APPLICANT: If. after making this Certifmcme of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
Ii,eorounitheis in the Worker's Compensation provisinna of the Lahnr Code, you must
forthwith comply with such provisions Or this petmit shall be deemed invoked.
BUILDING FEE
SEISMIC ITE '
CONSTRUCTION LENDING AGENCY
1 hereby Orion that There is a construction tending agency for the performance of
IM1e work for which thea permit is issued (Sec. ]RAO, Civ. C.)
Lcndefs Name
TOTAL:
ELECTRIC FEE
Lenders Address
Y=•f
QT1,':T MECHANICAL PERMI,T� -+aFBE
PLUMBING HE
I certify That 1 have read This application and state that the above information is
correct I.mm to complyvm1h.11 city end crout,mdimm. and state laws mluting to
' ''
PERMIT ISSUANCENa—
MECHANICAL. FHE
LA
building construction, and It by authonm representatives of this city to enter upon the
above-mentioned pmiteny inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, i d ify and keep homeless the City of Cupertino against
liabilities judgments, coats ex hich may inanyw cine egaisBt said City
AIR HANDLING UNIT (TO W." CFM)
in ctinequmeeofshe gain ofs t.
AIR HANDLING UNIT (OVER 10,1100 CFM)
Si,mmm.f AppOennUCo ton Date
IiXHAUSTHOOD(W/DUCPJ
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
Will the applicant or future building Occupant store or handle hawdous material
as defined by The Cupcninn Municipal Code. Chapter 9.12, and the Health and Safety
IlEiVfING UNIT (OVER 100,000 BTU)
O
Code, Section 25532(x)?
❑ Yes ❑ No
VENTILATION FAN (SINGLE RISID)
Will lM1cupplicanlnrfuturehuilJingarupans userquipmentordevicee which emit
BOILER - COMP (3HP OR 100,1X10 BTU)
ISSUANCE D tleM
BOILER - COMP(OVER 100,000 BTU)
In.o Jous an comaminants as defined by the Bay Area Air Quality Mma,untem
Distract?
❑ Yes ❑ No
NEW RESIDENTIAL. MECH.—SQ. FT.
I have mai the hazardous mmmals rcgemarnm s under Chapter, 6.95 of the
California Health & Safety Cade. Seen... 25505.25533 and 25574. 1 undemtand that
if the building Tres nut currently have a tenant that it is my responsibility, to notify the
ccupant of the rx,mirenmms which most he and poor a. issuance if a Cmi tame of
Occupancy.
SSUED Y:
Owner oraathnoaed agent Date
10TAU
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