28090 cAF?PLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
�Nr•'OaI�'t�.N1.v)- O• BUIL)ING-FillL0FR1'IpCAL LIC�
NP. PERMIT ON/PERMIT BUILDING PROJECT IDION O. OYL� ^y/OlS
w
OBUI DIVISION APPLICATIPLUMBING-MECHANICAL
BUIL ING ADDRESSIDSANUARYNO. APPIJCYGONSUBMII'FTAL DAT
E
6ADS ���
O NERSPIONG CONTRACTOR'S NAMN/C CONIKOLk
RCI III EC'I/FNGINEER: LIC NO: ADDRESS ❑ ���
CONI'ACF: Pn E: BUILDING PERMIT INFO
QTY. GLECI'RIC PERMIT FEL'
1. I1�E� .UMB
PERMIT ISSUANCE �ry`
LICENSED CONTRACTOR'S DECLARATION APPLIANCESISSUANESIDF.NTIAI.
pyZ Iherchyalfmllhal lamlicensedunderprovisionsofChapier9Pcom encingwith JOB DESCRIPTION
.100 Sectiun](KKBof Division3 afthe Businessand Professions Code,andmy liven.is in PANELS
FK full fora and eft G
Fi License as
Lim
.p�n��/) :? UI'T02(IO AMP'S •i' \T—C
viGoO Dude Contractor 201-["AMPS
Z8,-K ARCHITECT'S DECLARATION OVER IWO AMPS SQ.FT.FLOOR R A E/SQ.Pf.
cz—n l undcrsuy)nY Pia^s shallh u�3Iic records. //���k/�
cy- f?va�l SIGNS Ii1.F.C11tICAl.
Qi2a LittnsW Prdlessional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�C,wu 1 hereby mlirm Ilam I am cxetnpl from the Contractors License Law for the
m3ay following reason.(Section]03L5.1cminess and Professions Code:Any city or cnumy TEMP.METER OR POLE INST.
�C2J which requires a permit in constma,tote,Improve,deveolixh,or repair arty stmetute
WYEwil,issuunce, la. thea harem untruth ,to flea signed statement POWER DEVICES
prior rquirts pp permi gn
that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
KC� 9(ntmmendog with Section]INTO)of Jiv cion 3oflbe BudecanPro
sad fessions Cade) SWIMMING POOL ELECTRIC VAIUA11ON
W_m or that he is exempt therefrom and the basis for the alleged exemption.Any violation ofs,
OVI'LTi I'S-SWITCHES-FI%TLRf:S
�4Section 7031.5 by any applicant rarape.it subjects the appreanun a<ivil penalty of
not more than five hundred dollars S5W). .
t77
a, ca [II.mowneroftheproperty,ormyemphoyceswithwagesastheirsolecompemation, NEW RESIDENTIAL ELECTS S QFT. STORIES TYPE CONSTRUCTION
will do the work,and the structure is nol7mondedorollemd for sale(Sec. Business
and Professions Code:The Cummcdoes License law does not apply to an owner of
property who hadds or improves thereon,and who dnes such work himselfor through his
own I dud that suchim t t t ted proffered onsala lL OCC.GROUP RES,UNI employees,ebuildi vi pis sold n within
no in en
however,the building or improvement of proem is sold within one year of completion,the owner- O,
builder will have the harden of proving that be did not build or improve for purpose of
rate.).
❑ I,as ownentRhe property,um eadusivelycomructingwiWlicen.damtmmnrs into QTY. PLIIMHINC PERMIT FEF, FLOOD ZONE AI'N
coarmurt the project(Sea.7044,Bosiacss and Prnfes urns Cade)The Conposeams PERMIT ISSUANCE'
License Lawdeas not apply manownerofpmperty whobuihdsorimp soesthereon,and
who contracts havach pmjeab with aamtrtclm(s)licensed pursaantto the Contmerors ALTER-DRAIN VENT-
Licen.law. WATER(EA) PEL'SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTIiCI'.UIiVICI? O SIDE MES
SANI Y Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION CHOOL' Y N
hereby affirm that I have a cenifcam of<omem b self-imam,ora certificate of RECIfT#
Workers'Comproo,inn lnsmpron,milec"ifed copy thereof(Sce.3800,Il which PI%TURCS-PFdt TRAP Pp Y N
veers all crypt# this M RECEIPTN
Policyar l•/Yfm.� 9• GAS-BA.SYSTEM-I INC.401JTLhTS
W"mw �(� BUILDING DIVISION PEF
�p c GAS-13A.SYS1'F:MOVP.R4(GA) PLAN iF
❑ Cmified cbpy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASFfINDUSTRL WASTE INTERCF:PI'OR GRADING ITE st
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Othissenion necdnatbecomplemdifthepermitisforonehundrMdullins,S00) SEWER-SANITARY-STORM PA.201 ENERGY FEE
or less.)
I ceniEduld in the penfnnranccof the work for which this bull is issued,I shall WATER HEATER W/VENTIEh.ECIR
nm employ any person in any manner ao m to become subject m the Worker% PAID
Contpcnsmion lawsof California. Date WATER SYS'I'EM/TREATING Dme Receipt#
Q Z Applicant
0 NOTICE TO APPLICANT:If,after mukiri lhis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(ry hecOmesabjen m the Worker's Compensation powi,onsphlhe Lith nr Cale,you must
C� forthwith comply with such provisions or this permit shall be deemed residual. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC PEE
z
^Gf I hereby affirm that there is a consumption lending agency for the performance of
V r We work for which this permit is issued(Set.3097,Civ.CJ T ELECTRIC PEE
tenders Name
F Lcoder's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify Wad 1 have real this application and autocrat We above information is
Fcorrect.I agree to comply with all city and county ordinances and state laws«lating to t PERMIT ISSUANCE ' MECHANICAL FEE '
Cr� building construction,and hereby aulbnrim representatives ofthis city to enter upon the CONSTRUCTION TAX
V 7 tMve-mcorcurn l property for impaction puryos. ALTER OR ADD TO MECH.
.^� (pap)agree m sive,indemnify and keep handles,the City of Co'ninn against
IRfR,pd,mems,Wats veal expenses which may in any way accNe against said City AIR HANDLING UNIT QO I moo CFM)
me equenceof Wegry ut; pcmmn.
AIR HANDLING UNIT(OVER III,WOCPM)
,Ignaturcof Applieant/Cond cmr Date EXHAUST HOUD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE.
1{EAT'ING UNIT(TO 1013,0W BTU) Dam Receipt If
Wit I the applicant or future Municipal
C occupant store 2,handle hazardous materiel
m defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,OIX)B'I'U) TOTAL:
Code,Section 25532hp?
Cl Yes ❑No VEMf11,AT10N PAN(SINGLE RBSIU)
BOILER-COMP(311P OR POO,"BTU) ISSUAN( DTE
Will the applicant motion builJinga�cupam ueeequipmenWrdevices whichemit 0'_ 1 p�
haaallom air conundrums ua defied by the Bay Area AG Quality Management BOILER-COMP(OVER 100,000 LOU) V
DisVlpf7 0�
❑Yes 13No NEW RESIDENTIAL MF.CII. SQ,17. /� {/
I have road the homrdy
ous materials rcquircannits under Chapter 6.95 of the /1 1995
Califon is Health&Safety Code,Sections 25505.25533 and 25534.1 imd<mand that Vr 1
if the building Wises not cunen0y havcu¢nant,that it is my mspnnsibilirymnodify the
occupant of We requirements which muss be met prior m issuance of a Cenifctm of //ry(f
Occupancy.
Owner or auNoriud agent Dam A ISSUI3D BY: _
OFFICE