28429 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILDING-ELECTRICALMECHANICA PERMII'NO.
APPLICATION/PERMIT PLUMBING-MF.CHANICAL
BUILDING DIVISION BUILDING PROJECT'IUEMTIFICATION 28429
BUILDING ADDRESS- SANITARY NO, APPLICATION SUBMITTAL DATE
c)e .UNIT# LOT# 7
'?754__pH0 CONTRACfO I AME: LIC NO: NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE � I"A
LICENSED CONdandel'OwiduDECLARATION APPLIANCES-RESIDENTIAL JOB DF�ION
pyo, Ih70m)or rm Division
3 ofthnserinssrnd Probations
Ch ode. nd mmecense is iM1
,s100 Section finalOgBnf Division 3nf the Business and Professions Cade.and my license is in PANELS N.
<Z, License
las-ffut. �
FZW Date Claus Cmar IIP T0200A PS
m K Date GanT"S D 201-11%10 AMPS
CQy Z, ARCIIITECId as
OVER["AMPS
SQ.FT.FLOORARPA S/SQ.IT.
02-0 I understand my plans shall be uud es public xcnrdx.
Pr21zw
Licensed SIGNS ELECTRICAL
Professional
pS, a OWm BUILD HR DECLARATION SPECIAL CIRCUIT/MISC.
x OdF I hereby affirm NI am am exempt from the ContractorsCo License Law for the
NLLOm following'swaPemit to consmBusinmand Pro.demolish,
Code:Any city orcountyucture TEMP.METER OR POLE INS'I'.
C y which requires t permit re cores the altar,improve,demolish,or repair any structure
}0 that hoslicensedpursont to the
the applicant for permit's file asuc Lastmemenr POWER DEVICES
p thin he islicensedwpursuantmthe provisionsof the Contractor's and Pro Law(Chapter
a Xdo� 9(commeis(commencing tSecllonloo0)af bisisionJof Needeineas and Professions Code) SWIMMING POOL ELECTRIC VALUATION
yl_y Sect'sheit ISbythemfrrm and the ba.itsforbjemlegedexemption.Aivilpaatianof OUTLETS Section than byanrelood cantforepermitsubjectsthe upplicannovcivilprnulty or FIXTURES
TD t eown0vfflue, edrly.dolor yemp.
K Po sowneroHhe r NEW RESIDENTIALELECfIt _SQ.FT.
propclumimytinlcn dol.fwagesa.Ie(SolecompBusine , STORMS NPIi CONSTRUCTION
i3— wIdothewo3.endo:Tax Curbstone,
La it,(nrml apply Tl 44,Business
Professions Cede:The Convenor's License Law such
not apply to an owner of
co pcnyleyea.ldsorimpruves thereon,und who docs such workhimxlfonhroughhis
employees,lding edthmeuchcru is s ld witsnrennt earoferampleercd for owneL 50C CROUP RES.UNITS
however,the building burden
odpmcnt is sold a di inone year of completion,the owner- T
builder will have the burdrn of proving thin he did not build or improve for purpose of
sale.).
❑ I,as ownerofNe prop-ny,nmexdusively comr ins wiNlittnudconwcmrs to QTY. PLUMBING PERMIT FEE FLOOD ZONE pPN
onflmet the,prui-m(Sec.lfW4,Business o(euio oda:lZc Conrrutora
Li Muse Law does not epplytoen ownerof m whobuilrs vestherum,and PERMIT ISSUANCE
who contmeu for inch pmjems with.
_)'fix
me pumuem mthe Contrunar's WATER(EA)
License Lnw. ALTER-DRAIN&VENT- FEE SUMMARY
❑ 1 am exempt under
Su. ,B&P C for amn BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y_N
DataRECEIPT#
Ter WORKMANC fPENSATIONDECself-i ON DRAINS-FLOOR,ROOF,AREA,CONU. SCHOOL TAX Y N
❑ Ifterebear Coya(Bsm thnlasur marc ifie consentraul(S...3,or aC.)wjof FDOURES-PER TRAP RECEIPTN
Workeri Compenutian lmv ttmaunified ropy rherca((Sec.380. bCJ which PARK FEE Y N
mversallemployee'ssande is,andik GAS.EA.SYSTEM-IINC.4OUTLETS RECEIPT#
Policy p
Company BUILDING DIVISION FEB
❑ Certified copy shemby famished.• ///��� GAS-EA.SYSTEM-OVER 4IEA) PLANCHECK FEE
❑ Cenifiedcopy is filed with the city in ndiviximm I GREASP/INDUSTRL WASTE,INTERCEPTOR GRADING ME
CERT' ICAT'E [+XE ON PRO W ERS' GREASE TRAP SOUS FEE
COMP S NINS C�
(lTis�ction needn bac ' the itis now hundred dollus(S ) SEWER-SANITARY-STORM EA.201)FT. ENERGY FEE
or leu.)
Icenifyrhntinme,ei saveaI rhe walk far which this permit isissueI shml WATER HEATER WNENT/ELEM
nm employ say person in
_'
r so as to become mbject to the orkers PAID
z Compensation laws oft alifomin. Dam WATER SYSTENVIREATING Dam ReceiptN
O O Applicntn
NOTICE TO APPLICANT:If,after m in,this Cenificuta of Enemptio you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
y become subjecuothe Workers Cobi en m,r vaionsofthe=Px e,you must
a ; forthwith comply with ouch provisiorm ooh rmh stall be deemed oked. BUILDING FEE
a (] CONSTRUCTION L[JJDI AGENCY SEISMIC PEE
.=- z I hereby affirm thin there is a construction lendin n theperfmmanceof TOTAL: ELECTRIC FEE
U O the work for which this Permit is issued(Sec.3091,Civ.C.)c
LS. V Lender's Nome
O Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
I cenify that I have read this application and state that the above information is� MECHANICALMC
correct. I agree to comply with all city and county ordinances and slaw laws relating to PERMIT ISSUANCE
F" fA building comvanion,andhemby authorise representativesofrhiscity to cnterepon the CONSTRUCTION TAX
U z-. above-mentioned papery for inspection pur,mes. ALTERORADDTOMECH.
(We)agree to save,indemnify sod keep harmless the City of Colorti o agaimt
liabilities,judgments,costsand expenses which may in any weyaec � C AIR HANDLING UNIT(TO 10,00t,CFM)
onuquence ofth rantingofthspe
irmit. /e/i a (/
AIR HANDLING UNIT(OVER 10,(10)CFM)
aaaaa
S nmum -li onme'sr Dow EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM,"BTU) Date Receipt#
W ill the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Core.Chapter 9.12,and the Ilealth and Safety HEATING UNIT(OVER 100.00)BTU) TOT
Cade,Scmi 25532(s)?
11Yes El No VENTILATION FAN(SINGLE RESID) �s
❑
ISSUANCE DATE
Will thea licunmrfmurchuildln BOILER-COMP(3IiPOR IW,IXq BTU)
pp boy the Bay Area it Quality are-const
Distant? air contvninants m defined by the Bay Area Air Quality Managemrnt BOILER-COMP(OVER 100,IX1)BTU)
❑Year ❑No NEW RESIDENTIAL MECH. SQ.FT, PAID 1 haveread the hazardous materials requirements under Chapter 6.95 of the P IV
Califomin Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that JUL 1
if the building docs not currently have a tenant,that it is my responsibility to notify the
mcupom of Ne rcyuirements which must he met prior m issuance of a Cenifcute of
Occupancy. /s
Owneroramho mal rot Dme C (4
6 TOTAL: ISSUED BY:
OFFICE