28021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELKC I RJUAL PERMIT NO. 28021
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
gLDING ADDRESS: G/;n SANITARY NO. APPLICATION�S,UUBBMaITTAL DATE
✓r' 6
GS�NISrI f1k UNIT# LOT S-HCS
OW 'BS NAME a� PHON/E�: COhl OR'SNAM LIC NO:
OR l k= O/< R I SI
N/C CONTROL a
® A CHII'ECI'/13NGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE qG C PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �I�(r. _ - 'OB D�RI��
pyo IM17")ofrtnision licensed under provisions ofCTupmr9(commencing with 1`�FsT�/'✓C�
x100 Section]W5T)of Division 3 of the Business and Professions Code,and my license is in PANELS
c: full forceandeB¢t.
LQ.,ZW Liecrosc Class Lica UP TO 200AMPS
FN-jy Dole Commerce 201-LBW AMPS
oONL ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA $/SQ.IT.
O Z• C) 1 undcrswnJ my plans shall be used as public records.
SIGNS ELECTRICAL
6Y�j Licensed Professional
Nyy Q' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOgF I hereby affmr that I an exempt form the Cioun is License Lew for the
3 O rn following mason.(Securn 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
C uJ m`C which requires a permit to construct,alma improve,demolish,or repair any a
atuum
F o�Y :V prim to its issuance,also requires the applicant forsuch permit.file.signed souement POWER DEVICES
Iyy00 thin he is licensed pursuant 1.the prnvuions.fine Contndor's License Law(Chap¢r
°•Xo�' 9(commencing with Section Division 3 ofine Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ty_y or Section
tat olm iscwby any applicant
for a permit subjects
is the exemantto civiny 1pladon of OUTLETS-SWITCHES-FIXTURES '
Fo_Q Semon]7031.5 e,by.terefromand a basis frthecugeexemannoa civilpenaly.f
as p not morcthan Eve hundred dollars(SSW),y�o ❑ I.asowncmfthepmceny,ormyemployceswithwMesazthcirsolecompcnsetion, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE.CONSTRUCTION
will do the work,and the structure is not intendedorefferW forcall 7044.Business
and Pmfcainns Cedc The Contractors License Law does not apply to an owner of
property who buildsmimpmves thens n,and whodaes such wnd himselforthmngh his
Own noployees.provided that such impmeements arenolintended oroffered foraale.If, OCCGROUP RFS.UNITS
however,the buildingnr improvement is sold within One yearm completion,threatener.
builder will have the burden of moving that he did not build rr improve for purynse of
sale.).
❑ 1,asrwnerofthepropeny,amenclusivelycunoactingwithlicensedconoacto to QTY. PLUMBING PERMIT FEE FLOOD ZONE: APN
construct the project(Sec.7 W.Business and Professions Code:)The Contractor's
License Law does not apply to an owneoofpropeny who builds or improves thereon,and PERMIT ISSUANCE
o ho contracts for such projects with acontranos s)licensed pursuant to the Contactors
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O I'MIT FEES
OwnerSANITARY YN_
• Dam DRAINS.FLOOR.HOOF.AREA.COND. RECEIPI'Y
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Imiebyaf rmthat[haveacenificateofconsennoulf-insum.or a cenificam of FIXTURES-PER TRAP REC[IPfp
Workers'Cnmcensaton Insurance Or thereuf(Sec.JSW.Iab C.)which PARK FEE YN
n all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT.
Company
BUILDINGDIVISIO Fr'
Cn Cel GAS-IA.SYSTEM-OVER 4(EA)❑ Cenifed copy is hereby famished, !SEISMIC
IIECK FEE
❑ Certified cupy is filed with Neciry,inspection division. GRE,SE/INDU$TRL WASTE INTERCEPTOR NG FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP FEE
COMPENSATION INSURANCE
(Ibis section need not be completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM FA.2WFT. ENERGY FEE
or less.)
I certify that in the performance mite work For which this permit is issued,l shall WATER HEATER W/VENT/E K
rat employ any person m any manner so as m become subject to the Workers'
Z Compensation Lawsof Califomia Dam WATER SYSTB3y1/1' Daa RecciplN
Q O Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Esempuan,youshould NEW RESIDENTIAL TOTAL:
F (_q assume subject the Workers Compensation previsions of the Labor Code,you must
forthwith comply with such provisiom Or this aborm shall be deemed revoked.
� �_ ING FY:E
4 CONSTRUCTION LENDING AGENCY HE
Z1 hereby affirm that them is a constitution lending agency for the pcfrnmence ofthe work for which this permit is issued(See.3097,Civ.C.) TOTAL: RIC FEElenders Name
O Utenders Address TYCHANICAL PERMIT FEE BINGFEE �•c I artily that 1 have read this application and state that the.hove information is
orrcet. I agree to comply with all city and county ordinances and sum laws relating to PERMITISSUANCE NICAL FEE
_ fn buildingeonstuction,and hereby amhave representatives ofthis city t0 enter upon the
() Z u6we-nmmiuncJ property for inspection purposes. ALTERORADDTOMECII. CONSTRUCTION TAX
(We)agree m save,indemnify tion keep proposes.
s the City of Cupertino against
liabilities,judgments,costs and espenses which may in any way scseltea M)
sai C' AIR HANDLING UNIT lo."CF
ce of the gmnunof thi
g o omit.-7
mit.
AIR HANDLING UNIT(OVER 10,(010 CFM)
s
Signature Appl anUComna, Dat EXI MUST IIOOD(W/DUCD
PAID
I IAZARUOUS MAI'17RIALS DISCLOS URE HEATING UNIT(TO I W,000 BTU) Date Receipt srt
Will the applicant or foe building oecupamco
score or handle terrariums tra coal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health an I Safety HEATING UNIT(OVER Hat,LIIB BTU) TOTAL:
Code.Steelton 25532(.)4
El Yet 0 N VENTILATION FAN(SINGLE RESID)
Wta ilHheu licamorluwmbuildin ossa antuu BOILER-COMP QHPOR IW,IgOBTU) 1 U Iy DATE
PP B P equipment..devicesanagement
IIIIIIIIIIIIIIIkhnimct?s oil ttmtmninants m define)by the Be,Area Air Qualiry Management BOILER- ( nOq
Dismal COMP OVER I W,IIBO BTU) (r��H
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. /s/� 11
I have mad the hriardous materials requirements under Chapter 69 C
5 of the ����
Catherine Health&Safety Code,Sections 25505,25533 and 25534. I understand Out atm Y()/. GUPrN1'p y
if the building docs not currently have tenant,that it is my responsibility malty the OOesu /•1
mcupan of the rcyuircmena wM1ich must be met poor to issuance of a Ccnifate of ,�`/s///�(///$/)
Owner ser authunacd agcm Dme
TOTAL: ISSUED tlY:
OFFIC