25294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - B RTIC-ELN.CTRI AI. FERMI rNO, r^ Q
BUILDING DIVISION APPLICATION/PERMIT PI'IJMP'VG-MECHANICAL Z V Z V
Run 5D ;iBR
-ROC'T IDENTU ICA'1'ION
BUILDING ADDRESS: SANITARY NO. JAPPLICATION SUBMITTAL DATE.
>• 2 5a —UNNIT# LOT# �� _
I OWNHRSNAME PHONE: COI�TtAC' R'S NA E: T LICNO: N/C CONTNOLp
S
IARCII ECT/ENGINEER: LIC NO: AD`RESS' , � a 13 �6
CONTACh PHONE: a'
• QTY. EI,ECI'RIC PF,RMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IP LOB DESCRIPTION Ld
qy.Z I hereby affimt mal l am licensed underprovisions ofChapter9 onmmenciagwiN
sQ00 Section V00(Bm(Division3mf the Beliness and Professions Cole,and my license is in PANELS
�u— muma,Claderr«,.
F-qqW I.icense Clavi Lic.N UP T02(0 AMPS O'
hay Dare Commemr 2UI-If%0 AMPS
Z�NZ ARCHITECTS DECLARATION OVER IOW AMPS SO.M.FLOOR AREA $/SQ.FT.
I understand my plans shall he used as public records.
rn JSIGNS ELECTRICAL
Q3y Licensed Proressimord
KK OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
(:O y F 1 hereby union that 1 um exempt from the Contractor's License Law for the
I+�'+Qm following reason.(Section 7031.5,Business and professions Code:Any city or county TFMP.METER OR POLE INS('.
�ISy� which requires a permit e,rent Won,improve demolish,or repair any stmaum
LNY� prior In its issuance,also requires the applicant for ranch periuo file a signed statement POWER DEVICES
� �0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC aap�' 9(Commencing with Section 7090)of Division 3 orme Business and Professions Code) VALUATION
❑rn orthm he iiescrapa themfram undthe basis!onheallegedexemption.Any violation of O(ITLEI'S-SWRCHPS-EIXTIIRES ���'''777
HZa Section 7031.5 byanyapplicant fore permilsubjens the applicnnuancivil penahyof �j� 7�/��
� q not more than Eve hundred dollars($5W). NEWRESIDENUFIALELECTR S .FT. I /
ec ❑ I,asowneroftheprmpcray,ormyemployeeswithwugesuuheirsolecompensation,' Q STORIES TYPECONST(UCTION
ty will Bothework,aide The ontactotintende..Law does .,apply 1.ancovin,of
and Pmfwho bu Cade:The Cnmmmm's License law does not apply m an owner of s
propenywyeas,provi improt such improvedwho dcessuch work himselfar through his OCC.GROUP NITS.UNITS
own emploebuiliovi or improve improvements suld within
not yea ofdoroffered the ow. r-
howevegtheavet a or improvement issoldwithi none yen of roprovef for
owner-
builder will have the burden of proving that he did not build or improve for purynse of
sole.). QTY. PLUMBING PERMIT FEE FLOODLGNE APN
❑ Las r joct(Sao ny,7"ameaduss and mmcting withde:) Ile Contractors
onsrruct the project(Sao 9041,Business and Professions Code:) Ile Comrumor'e
License Lawdo notaMlytoanownerofpropenywhobuildsmimpravesthereon,end PERM]FISSUANCE
whomnt.111 for such projeaswithacnmructor(s)IicenscJ purean., 'he Commmn, ALLIES-DRAIN&VIiNT-WATER THAT s:
License Law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUT'ID
SANITARY Y—N
—
Owner Dam RECEIITN
DRAINS-FLOOR,ROOF,AREA,CON D.
WORKMAN COMPENSATION DECLARATION SCIIOOL'I'A% Y N
$I Ih<rcM1y affirm that lhave ecenificare ofconsem msel4insurt.ora certificate of IgXTURES-PER TRAP RECBIITN
Wmders'Compenanrimn lnsurwcenracenlfied copy thereof(Ste.3gfNl,Lnb CJ whicM1 PARK FEB V N
covers all employee's under this permit. OAS-EA.SYSTEM. INC.4 OUTLETS RECEIPT'N
I'mlicyN - BUTIJANIB,DIVISION ES
Company— T'p' GAS-FA.SYSTEM OVER 4(EA) PLANCHECK FE
❑ CertiEul copy is hareby lumished. A 'C�
R�CenifieJ copy is filed with the city inspcctinndivision. r r GRIASEANDUSTRL WASTF.1 •PI'O GRADING
CERTIFICATE OF EXEMPTION FROM WORKER$' l" �' GRE TRA. SOILS FEP
COMPENSATION INSURANCE LL 0 .
(This serum,acednm be completed if the permit is permit hundred dollars 1$)N11' '\ SE �N A Y- TO FI'. ENERG FEE NI N
or less.) �7p `
0.
I cenif Elam lathe peRonnanceof the work for which Of,perrad is issued,)she) WATER" AT'F E / li 6R�a
not employ,any person in any manner.o as to become subject to the Workeri PAID
z Compensation lawn of California. Date AT WATER. •' Data Rea•
Applicant _
Q0 NOTICF.TO APPLICANT:ll;oftermnking this Cenificute of F.nemption,yousbould NI:P'RESIDENTIAL PLMB. SQ,FT. TVA
become subject to the Worker's Compensation provisions of the lalror Code,you must
� ? r mnhwith comply with such provisions or this peril shall be deemed revoked. BUILDING TEE
W z
CONSTRUCTION[.ENDING AGENCY SEISMIC PEE
rrC// I hereby affirm that there is a conswction lending agency for the perfmrence of F.LECIRIC PEC;
� r. Ihe work for which this pok Is Issued(Sec 3097,Civ.C.)
rLendels Name PLUMBING ITT.
Lenders Address QTY. MECHANICAL PERMIT' FEE
U 1 certify but I have read this application and mme that Ihe alwvt information is
J0. cars,lu ureom 1 d,all cit dcount g MECHANICAL FEE
gree pYwi yon yoNinances and vum)ewe relmin m PIiRMI'1'15SUANCE
bui1m,.mnstmaimm,and hereby amhmnre rcpmsenemives of lhi.ary menmr opo.the
1..1 above-memimned property,for inspection purpose.. ALTER OR ADO TO MECII. CONS'rItUCT10N B'AX
Two)....a w shot,indemnify and keep harm[eas the City of Cupertino uginma
hidilities,judgars, re,ts.J expenses which mayin any wayaccmeagainst said City AIR HANDLING UNTITO 10,(X0 CFM)
inConxeyucncc ba grunting of thi.vp
-/ AIR HANDLING UNIT(OVER 10,0011 CFM)
$' en ontremJl ,S/5/'� Uatc EXHAUST HOOD(WMUC'n
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]'I'(TO 100,000 BTU) Dam ReceiplN
Will the applicant or future building occupant store or handle hasardous material
ee definedbythe Cupertino Municipal Cafe,Chupmr 9.12,mnd the Health and Safety 1117ATING UNIT(OVER 10QIX0 BTU) T
Cade,Semina 25532ho?
11 Yes 11 No VENTILATION FAN(SINGLE RFSID)
BOILER-COME CTE IF OR 100(00 BTU) P A }rc NCE DATE
Will the applicant or futurehuilJingaccupam m ,
useeyuipmcordevlces which emit T .
x sarmdaus air commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER]BLOW BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. SEP - 2199_
I for.read the harardous mmen.N requirements under Chapter 6.95 of the v CSIIIVfaJ
- CalifomLJ lcalrh&Safety G,Aq Sections 25505,25533 and 25534, Iunderstandrhut �`11x Ur Vk
if the building does not cumemly have a reason,that it is my respershility,to notify the
exacriTtan,of the requirements which must be met prior m Issuance of.Cenificte of
Occupancy.
Ownermr uulhonzed agent Dam l ISSUED BY:
OFFIC