27836 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO I ILIU -F. h. N AI. PERMIT NO.
APPLICATION/PERMIT PING FROG-MECHANICAL
IFICA 27836 7 8 3 C
BUILDING DIVISION BUILDING PROdECT1UEN1'IfICA'TIpN G ` v
BUILDING ADDRESS: (� SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT#
OWNERS NAMH: PHONE: CO CT R'SN E:
N/C CON]ROLN
RCHITECf4:NGINECR: LIC NO: ADDRES ❑ ��l .
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PER
BLDG ELECT PLUMB MEGA
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OKZ I herebyaffirm that l not licensed underpmvisioos of Chapter 9(commencing with
tit-U fall force 7")ofDivisionc3of the Business and Professions Code,and my license is in PANELS �
OC-USection 7 and effect
FZtLicense Class Lic.# UPT02MAMPS
w 4 y eso
Dao Contractor 201-10(10 AMPS
Z Oyu ARCHITECTS DECLARATION OVER IOW AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
p Z os p I understand my plans shall he used as public records.
j,.t u..111 SIGNS ELECTRICAL.
�Q f..l Licensed Professional
�gf<F OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOy1 hereby affirm that 1 am exempt tram the Correctors License Law for the
u134m following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ES�� which its issuance,
ss a u permit o construct,alter,improve,demolish,nr repair any statement
g<0z priorat e itssicensed pursuant
i the
thevisios of tht for e Comorch minaLiceseLad statement POWER DEVICES
Gp 9 promnnerrinsnith Smm i7").f Division
the nor Bit .,.
Licenselaw(Chapter
LLpLL 9(commacing with Sation]t10p)of Division3of rhe Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
q _y
or that he is exempt hmcfrom and the hnsis for the all exemption.Any violation of
FZa Section 7031.5 by any applicant foraOUTLETS-SWITCHES-FTXTURFS
permit soli' the pplicannoacivil penalty of
p not mom than five hundred dollars(1500). NEW RESIDEMTIAL ELEC R FT
5 .
[ILazowneroDheprnpeny,ormye yeeswirhwage astheiraolecompensation, Q STORIES TYPECONSTRUC ION
a will do thework,and the structure i tmendedoroffereJf sale(Sec.]044,Business
and Professions Crule:no factor's License law does t apply m m owner of
pmpertywhobuilds proves thcrso ,and whodoes such wit himselfmthroughhis
ample roviJWthat such improvememame not intense rofferedforsale.If.
OCC.GROUP RES.UNITS
however, ebuildingorimpmvemenI i�ruldwithinoaeyearofco Ietion,theawner- TOTAL:
builder ani have the Mena rovin he did not build or int eforpurpoi, of
sale)
❑ Laza nerofrh lycostrining with licensed connactonm QTY. PLUMBING PERMIT FEE FIDODZONE APN
nswct the o ] x mese onA Professio ale:7 The Contractor's
License Law r annwnendpmperty who ilds orimpmven Hereon,and PERMIT ISSUANCE
whoconvnetsl much to with aconaumugs) nsm1pursum,t.the Commnor's
License Law. ALTER.-DRAIN&VENT-WATER(EA) FEE SUMMARY
E] I am exam a urge a. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY UUTY D S N
Owner Data DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT#
RKM COMPENSATION DECLARATION SCHOOLTAX Y N
❑ lhertbyafOrm have a cenificate ofemsem.,self-insurcora certificate of FlJ(TURES-PP.R TRAP RECEIPTp
Wmkera'Compensotion Insurance oroceni0cA copy thereof(Sec.3gW,Lab C.)which PARK FEE Y N
covers all employce'a under this permit. GAS-EA.SYSTEM-I INCA OUTLETS RECEI Pr N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FZE
❑ Cmi0ed copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFpNDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thi,oa!Won need..,be completed ifthe permit is Corona hundred dollen($100) SEWER-SANITARY.STORM FA.200T. ENERGY FEE
or less.)
I certify thatOthe performance a fine work for which this permit is issued,Island] WATER HEATER WNENT/ELECTR
not employ any person in any manner so m to become subject tat the Workers' PAID
z Compensation Lawsof Califonua. Date WATER SYSTEMITREATING pare a t
Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,y..should NEW RESIDENTIAL PLMB. SQ.FT. T TAL:
r V- become subject to the Worker's Compensation provisions of the Labor Code,you most
La^ forthwith comply with,such provisions m0iis permit shall be deemed revoked. BUILDING FEE
UJ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm thauhere is a construction lending agency for the perfmmanee of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sm.3097.Civ.CJ
Lenders Name
C) U tinder's Address QTY, MECHANICAL PERMIT ITE PLUMBING EEE
I certify that I have read this application end state that the ahove Information is
rorrem. lu nmtor m thallcit de...l dirncea and state laws relatin m PERMIT ISSUANCE MECIIANICALFEE
8 pywi yen ym g
CI) building consuunion,and hereby emhoriu rcpres<mmivesof this city to cnteropon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection puTmes. ALTER OR ADD TO MPH.
(We)agree to save,indemnify and kap harsrks.the City f Cupertino against
Iiabiliti en .costs and xpm Aichnm many ay rue agninstim dy AIR HANDLING UNIT(TO IO,Oo)CFM)
in co a eof to gremin f.i it.
411 AIR HANDLING UNIT(OVER 10.000 CFM)
eof Applicam/Contractor a, ate EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"BTU) Dal Receipt#
Will the applicant or future building me.pant store m handle havtdous mater ad
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM"BTU) TOTAL:
Coda Section 255R(e)?
11Yes 11 No VENTILATION PAN(SINGLE REBID)
❑
Will the applicantor futurehuildingcecupum useequipmem or Jeviceswhichemit
BOILER-COME QHP OR IOQWO BTU) ISSUANCE DATE
aamitma air contaminant not as defined by the Bay Area Air Quality Maualtma m
BOILER-COMP(OVER 1010,0700 BTU)
)islrict?
❑Y. ❑No NEW RESIDENTIAL.MECH.-SQ,FT.
I have read the lissom us materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my ormnnaihility to notify Ne
occupant of the mgaircmants which must bar met prior to issuance of a Certificate of
Occupancy, yCY�Isr
Owner or authorized agent Date TOTAL: ISSUED BY "
OFFICE