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MECHANICAL 7.
CITY OF CUPESION PING PROJECT IDMU
BUILDING DIVISION APPLICATION/PERMIT nmE.InNerxodECTU)vrvTfxlcnTUiN
PERMIT NO.
Bll GADDRESS:
SANITARY NO.
APPLICA'I ION SUBMITTAL DATE
Sjalt ` lam. UNITN LOT#
tIVSY// �Vr
11 O NI: NAME: PHONE: CONTRACTOR'S NAME: LIC NO
1 %r s . / _ O
N/C
CONTROL. #
A TF.0 /F GENEF =1 N ` ADDRESLZ ArUJIBBIA
�#
Joe
CONTACT: PHONE:
Q'I.Y.
� * } 1'ELECTRIC PERMIT
- I, i
FEE:
i (BUILDING PERMITINFG
L ELFLJ PLUMB MECH
PERMIT ISSUANCE
❑ El
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that l am licensed underpmvixions of Chapher9 (commencing with
Section 7") of Division 3 of the Business and Professions Cade, and my license is in
APPLIANCES - RESIDENTIAL
PANELS
BDESCRIPI'ION
fullforreeandef I.
Lie Clan • Lic.N�
me Ve 7/4 Comrecmr��A � a
I1 P TO2W AMPS
r
201.1"AMPS
SQ. F 1'. FLOOR AREA
FT.
AR CHITECTS DECLARATION
OVER IOW AMPS
1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER - BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 on exempt from the Contractor's License Law for Ne
following eaon. ( Section 7031.5, Business and Professions Cede: Any city or county
TEMP. METER OR POLE INST.
which requires a perit to concoct, elan, improve. demolish, or rtIsw any sox .
prism,, its issuance. sh.unuima the epplicant (nr.ach permilm file. aigned suermia
POWER DEVICES
Thal he is licensed pursuant to the pnwisiorm of the Contractors License Law (Chapter
9( commencing with Section 70M)of Division 3 ofthe Barmesaend Profession, Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Suction 9 031.5 by any applicant for a permit subjects the applicant o a civil penalty of
SWIMMING POOL BLECILIC
VALUA'fJ��/a
1 00 a
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars ($500).
❑ 1,asowneroflbeprop y, t) rmyemployceswithwagesoslheirsolecompensation,
.
NEW RESIDENTIAL ELECTR S Q FT.
STO ILS
TYPECONSTRUCTION
/
-
will do the work, and lheswcwmis ammendedure ffemd for sale (See. 7N4, Business
and Professions Cole: The Common's License Law does nor apply to an owner of
l
property whobuitdsorimprovesther eon, andwhodoessuchwod hlmsolforNroughlds
con employees, provided thmsuchimprovementsmenol inlendedoroffered foraale.IL
however, the building nr imprtvcomm is sold wllhinoneyeur ofcompletion, Iheovorm,
builder will have the burden of proving that he did not build or improve for purpose of
"P
1V{ JY
RIS. UNITS
I
QTY.
PLUMBING PERMIT
'F:E
N.
APN
sale.).
❑ I, asownernfthepmpwy,. mexclusivelycontuctingwilhlicena ...,.sto
o isum, the project (Sat. 9044, Business end Professions Code:) The Cmm�nor's
LicensoLowdoesnol upplymannwnerefprt,peny whoboildsorimprosesthereon ,end
PERMIT ISSUANCE
whocommcts for such projects with a contrnctm(s) licensed pursuant to the Commcmr's
License Law.
ALTER - DRAIN & VIiNT - WATER GA)
FEE SUMMARY
❑ 1 am exempt under Sec. . B & P C for This reason
BACK FLOW PROTECT. DEVICE
OIITSID . i.
SANITARY YN
RECIiI PT#
Owner Date
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCBOOLTAX Y N
FIXTURES -PER TRAP
❑ Thereby affirm lhetlhaveacertificau of nmsenno self - insure. ornttnificem of
/ Workers' Compensation Insurance or acediried copy lhereof(See. 3BW,lab C.) which
covers all employee's under this pemlit.
Pol icy #
RECEIPT#
PARK PEE. Y N
R. E
GAS - EA. SYSTEM. I INC. 4 OUTLETS
NUIhDING (VISION SION FEES
Company
GAS - G. SYSTEM- OVER4(III
PLANCEIECK FEE
❑ Cenified copy is hereby famished.
GREASFJINDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FE
ENERGY FF.F
(This section need not becompleted ifthe permit is forone hundred dollars(SIM)
or less.)
WATER HR TER W/VENT/ELECTR
PAID
I certify that in the performance ofthe work for which this permit is issued, )shall
not employ any person in any mermen so as In hecmme subject ro the Wmkers'
Compereation Lawsof Califomia. Date
WATER SYSTENUTREATING
ale Receipt If
Applicant
NOTICE TO APPLICANT: if. a@ r making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject m the Worker. Compensation provisions of the Labor Code, you must
forthwith comply with such Provisions or this peril shall be deemed revoked.
BUILDING EE
/BB
CONSTRUCTION LEiNDING AGENCY
1 hereby affirm Nat them is a construction lending ag ency for the performance of the work for which this peril is issued (Set. 3WO, Cis. C.)
TOTAL:
FSEISMICME
E
QTY.
MECHANICAL PERMIT
FEE
FEE;
:,courts Name
Lender's Address
1 certify that I have mad this application and state that the above infaration is
correct. I agree to comply with all city and county ordinances and sou laws relating to
PERMIT ISSUANCE
L FE E
building conswction, and hereby authorize repmunutivesof this city , enter upon the
slaw.- mentioned ptnpeny for inspection purprses.
ALTER OR ADD TO MECH.
ION TAX
AIR HANDLING UNIT (TO 10." CFM)
(We) agree m serve, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, msss= de xpenuewhichmuyinmywryaccmeagaiml said City
AIR HANDLING UNIT (OVER 14000 CFM)
in corns ace of the do of this peril.
EXHAUST HOOD (W /DUCT)
PAID
Si, nm ofA feat ctor Hato
HEATING UNIT (TO 100.0011 BTU)
HAZARDOUS MATERIALS DISCLOSURE
are Receipt
HEATING UNIT (OVER 100,00089' U)
TO
Will the appllaun or from, building navpanl store or handle frmrdota material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safery
VEN•IILATION FAN (SINGLE RUID)
�.
Code, Section 35532(a)?
❑ Yes ❑ No
Will the applicant or future building occupunl use equipment ordevices which emit
BOILER - COMP (31 IF OR 100,01) BTU)
y$
JF1J E ATE
haurdeus air contaminants us defined by the Buy Area Air Quality Management
BOILER - COMP (OVER 100,0M) BTU)
2 U 1993
NEW RESIDENTIAL MECH.—SQ. IT.
�iBaWl? ❑ Yes ❑ No
[JUL
1 have mud the haxurdmu materials requirements under Chapter 6.95 of the
California Health & Safely Cede, Sections 25505.25533 and 25534. 1 understand that
if the building does not curren0y have a unanWhat it is my responsibility to notify the
y�g �r
11 ,
r
occupant of the requirements which must be met prior to issuance of o Cenificam of
Occupancy.
i.�
ISSUED BY
Owner er mahmired agent Dam
TOTAL:
U"Iut