25564APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO D,t•- -TR A PERMITNO.
APPLICATION/PERMIT PLu,Memc.MecxANICAL 9 R � F L
BUILDING DMSION ...�....a.arrwnn sten RING- r MECHANICAL
nu:s.xutr....esn
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OFFICE
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ONTACT.
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cJ/vrf e.l ONE:
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BUDL:DECITNO PERLMUIMT.BINPO t'MtN:EA: m
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0 0Y
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby infirm that l am licensedunderpmvisiou of Chapar9(commenting with
Section 70W) of Division 3 of the Business and Professions Code, and my license is in
fall force
so Cledou"b". e /��e1//
sat Class /�3 Lic.N G �l
meC
APPLIANCES - RESIDENTIAL
PANELS
UPTO200AMPS
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I^t100
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TOB DESCRIPTION
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6.•s O IPT' Fd�
301 - 1000 AMPS
CTZIr
ARCF If1ECTS DECUBATION
1 understand my plans shall W used u public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELEMICA
as
Licensed Professional
OWNER -BUILDER the Co ATION
1 hereby affirm thm 1 am exempt from the Canvactora License law for the
following rt^smt, (Saban 7031.5. Bushsw W Pmfwions Code: My city or county
which requires a permit to construct, alta, Improve. demalech. se repair any'.
pdo arts issuance,daomqui=a eaRlicutfmauchpamiuofrleuigmdsutement
that he is fiarud punuent to the provisions of she Contractor. U. law (Chapter
9(exmmeming with Section 7000)of Division 3 of Ne Business and Professions Cade)
or that he is exempt therefrom and fie basis for the ellegd exemption. My vialdon of
Section7031.5 by any epplicentf.• pemambjav Ns. applicant w a civil pebWry of
n mom Nen five hundred dollen ($5W).
❑ 1,uawnaofNepropety,mmyvmployeawithwegauthviraolecompcwsion,
SPEC UR C
TEMP R IE T.
E
BWI IN POOL [LECIAIC
VALUATI
t y`
O ETS SWITCHES -FIXTURES
NEW RESIDINIIAL ELECIR SQFT
_. .
STORIES
TYP CO STR CTIC
willdothewort,aadthestruaureisnotimmndedmaff Nfw We(SM.7M4.Bmima
And Professions Code: The Convectors License Law dm not apply to an owns of
property wMbuildsorimpmvathereon,udwhodoasuchwor Mh lfmthwughhis
emplayaa,providddwauch improvemcouuemtimeadd malaadim We. IL
OCC.GRO P
RES. NITS
TO1.AU
haweva, thebuildingorimprovancotis mrd withinom Yeuo(mmPldan, the ower-
builder will have the bmdco of proving that he did wt build or improve for purpose of
u
rowal ��.v P6E
We.).
❑ I,uowmrofNe propary,emucluivelymbtracvn6 witAlisrn.Memvactrasto
constrYa the project (Sec. 7044, Basin. and Profeuiou Cade:) The Convacton.
License Wwdmsnoupplywmownaofpropetywhobuil&mor pmvnffic g, nd
FL OZONE
APN
PERMIT ISSUANCE
who contracts fm each projects with a convector(s) littnudpbabont in the Contractors
U.. Law.
ALTER (EA)
:
q,s. ,, PEEJSUFUfAR„�
❑ Ism exempt under Sat. , B & P C for this moon
BACK FLOW PROTECT. DEVI
SANITARY Y _N
Cavi Date
WORKMAN COMPENSATION DECLARATION
❑
Waskat CoIrs'Co affumIlhaveewtifitzu ofrnuemwself-ivsure,or emrdfieve of
mpensatioonnImmanence m ecatifiedso” thvwf(See 3800, lab C.) which
DRAINS - FLOOR ROOF. AREA, CON
)x
s;rt,
CNil
�s.
RE�IPrN
SCHOOL TAX YN
RECFIPI'N
d -PER
PARK FEE YN_
covrn ell anploYa's undo tlda pvmih
PoIiryN -�
' REC.
OAS -EA. BY 4,%C. 4OUTETS
BUILDING DIVISIONSION FEES
Company -
OAS-
PIANCHECK FEE
C3Cafifiedcopyiehembyfumiahed.
WASTE R -
GRADING FFP
❑ Certthnd copy i, filed with the city inspection divW.
CERTIFICATE OF EGU41`770N FROM WORKERS'
COMPENSATION INSURANCE
G
SOILS FEE
S S STORM EA.=)FT.
ENERGY FEE ,
(Thiaaection send twtMcomPltted if the permit uforomhundrddoll 100)
or leu.)
WA HEATER WIVENTIEIF,CIit
Iccrafy theinthepoef.ce.fbhewort fmwbichthispemm uiasud, I
wt employ any perms in try mamba so u w berome subject w the Work
PAID '
0 Z
Q
Compensvtion Lows, of California. Due
Applicant
NOTICE TO APPLICANT:ILafter meting this CeNfiace of Exemption, you should
WATER SYSTEWTRFATINO
NEW RESIDENTW-PLMB. SQ. PT.
Due Receipt .
,
TOTAL,
En
becamesubject to the Worker. Compevation provuiou of the labor Cde, you must
•
fosthwithcomply with such previcimu.,his permit shell be deemd meted.
BUILDING FEE O
SEISMIC FEE
y Q
CONSTRUCTION LENDING AGENCY
V C)
c)
O
i"
V Z
1 hereby aforn that chase u a comtmction leading aBenaT far the paforrnuue of
cls wort fen which Ods permit I. laved (Sec. 309'1, Civ. C.)
TOTAL
ELECTRIC FEC
Lender. Name
Lender'. Address
1 ramify Jw I have read chi..'fication ad rote dw du ;hove infonnetim is
correct. I agree to comply with all city and county eNin;m:a;d wu law. cvlating to
building construction. and hereby authorise rcpracoutiva of dda city m cora upon the
above-mcotiond Property for inspection purp.es.
:en
w'ibi s+.: . ri
PLUMBING FEE
PERMITISSUANCE
ALTER OR ADD TO MECH.
MECHANICAL FEE - -
CONSTRUCTION TAX
'-t
(We) agree rams.. indemnify and tap hsrmlrss the City of Cupmirw agvnst
Babilitia,judgmenu, coats udexpeua whichm;yin try way axme against said Chy
AIR HANDLING UNIT (TO 10,M CFM)
memasol aofthegrMdng of thB11.
AIR HANDLING UNIT (DYER 10,000 CFM)
EXHAUST HOOD (W/DUCO
PAID
S' of Applicub/C tract. Dau
HEATING UNIT (TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt N
Will theapplicucor fuave building occupenc scene. handle haurdons materiel
u defind by the Cupertino Municipal Cde, Chapter 9.12, and Ns. f1ea1N and Sefery
HEATING UNIT (OVER 100,000 BTU)
TOTAL
VENTILATION FAN (SINGLE ESSIG)
(a)T
Code,Secden Year
❑ Ya ❑ Na
BORER -COMP (3HP OR 100,.00 BTU)
ISSUANCE DATE
Willtbeapplicurorfummbuildingomup tunequipmentordevicnwhichcmit
vJwadtws
BORER- COMP (OVM 10),000 BTID
1`
& contaminants a defumd by the Bey A. Au Quality Mattagami
❑ Yes ❑ No
P
PAID
NEW RESIDPNRAL MECH. SQ. FT.
I have read the haadous mamtial. rtyui.es uada Chayes 6.95 of dte
Californialieulth&Safay Cde.Sectiobn25505.35533atM 534. 1uadermnd Nee
if the building docanot currently have. .4 that is u my maponsibility w notify the
%Ibz I 1
pT� .
vat
occupant of the requirements which mut d met prim to ismanee of a Certificate of
U/
(rVrC
Occupancy.
ISSUED BY:
Owner or amhorissd .gam Dore
TOTAL: I
OFFICE