25277APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B°D.l1IN°-BExcrnlcA'
APPLICATION/PERMIT 19,UMRING-MECHANICAL,
BUILDING DIVISION BUILDING PROJECT' IDFNTIFICA-1'ION
PERMffNO Irl 7 7
252 1 1
BUILDING ADDRESS:/f/.�/'
/ / 6O✓(�/ A/r �/� UNIT LOT
SANITARY NO.
APPLICATIONSUBMITTALDATE
OWNIi NAME: PHONE.
C ACT'OR'S NAME: LIC NO:
Tt
NBC
❑
CONTROLp
ARCHITECT/ENGINEER: LIC NO:
RESS: I
CONTACT: PHONE:
6)Aazlec, Name
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLD EL tC' PLUMB MECf{
PERMIT ISSUANCE
w>i yy6 - 0% t 3
El El
LICENSED CONTRACTOR'S DECLARATION
Ihetebyaffrm that l am licensed undcrpmvisionsofChapter9(commencingwith
APPLIANCES -RESIDENTIAL
Salion 70001 of Division 3 of the Business and Professions Cod, and my license is in
force I. _ of
Lianx Ems ic.gYY
Dae Crmmctm J! C
ARCHITECTS DECLARATION
I understand my plans shall h used m public records.
PANELS
IIP T02W AMP$
, ,JO�Ba.DaPSCRII'1'ION
201 - IOW AMPS \
SQ. Ff. FLOOR AREA
S/SQ. FT.
OVER IOW AMPS
SIGNS ELECTRt CAL is
Licensed Pndeesional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC\
I hereby that I am exempt from the Contractor's License law for the
n (Se sitesdart Code: Any city
fallowing reason (Section 0031.5,
TEMP.MEfEft OR POLE INST.
ve dioions
stcounty
construct, repair ed ewaura
pri rM1 rite is, x o permit requirthdirect improve, demolish, file
icersed tproisionsmfore pennies fileaset-d sa
'
POWER DEVICES
-
that hes person to the Upleyncot
9(Comis licing with Swlorn70apmvisvision the Contractor's,BusinsLicense Law(Chode)
9(commencingwith$cmion0( d eDivision3ethe Business and Profusions Code)
or that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
Section 7031.5 bymyapplicant fora Permit subject, the uppllcenuoacEvil Penalty of
SWIMMING POOL ELECTRIC
in
��VAhUA
(,J
OUTLETS - SWITCHES - FlXTURFS
notmore than five hundred dollars ($500).
❑ I,asownerofthepmp M.ormyemploymswinhwagesu WeiTaolecompe.d.,
NEW RESIDENTIAL FYECIR SQ. FT.
STORIES
TYPECONSTRUC ION
w i I I Jo the work, aM the swctum is nos i ntended or offered fm Bele (Sm.7D14, B usiness
and Professions Code: The Cannot License Law does not apply to an owner of
property whobuildsorimpmvesthexon, and whoduu such took himxlforthmughhis
employees, prov ided that such i mpmvements arc not mm�Jed or of fared fm sale. IE
OCC GROUP
RES. UNITS
T L
however, the building or improvement is sold within one yemo(completion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
PLUMBING PERMIT FEE
sale')'QTY.
❑ I. as ownerofihe property, am exclusively contracting with licensed contractors to
FLOOD ZONE
APN
mamet rho project (Sea. 90.44, Business and Profession' Cede:) The Contractor's
License Law docs not apply tout, ownerofproperty who builds or improvesthereon,and
PERMIT ISSUANCE
whocnntmets for such projects with a contract nr(s) licensed pursuant m the Contrecmr's
Liamc haw.
AL'TF,R - DRAIN &VENT -WATER (EA)
FEE SUMMARY
❑ I um exempt under Sec. . B & P C for Nis reason
BACK PLOW PROTECT. D
DRAINS-Fl.pOR,ROOF,A O. D.
TSIDE FEES
SAN Y Y N
BE film
SCH YN
Owner Da¢
WORKMAN COMPENSATION DECLARATION
❑ E hereby affinnthat l have acerificane ofconsem tosel6insure.oracertificane of
Workers' Commmion Insurance ar a certified copy R f(Sec. 38W. lab C.) which
pe
Covers all employees uMer this pc.iL
Policy M
FIXTURES TRAPlivi
RECEIPTp
Y N
RDIVISIOCEIPT p
GAS - EA. SYSTEM -1 INCA O
BUILDING DIVISION FEES
Company
i �"
GAS - EA. SYSTEM-isi 4 (EA)
rCK FL
❑ Cedifiedcopyisherebyfumished.
—
GREAStyINDUSTRL WASTE INTERCEPTOR
GRADINGM
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION PROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY- ST ORM EA. 200111.
ENERGY FEE
(This section need not be completed if the pernir is forone hundred dollars ($100)
or less.)
WAITER HEATER W/VENT/ELECTR
I certify that in Ne performance of the work for which this permit is issued, l shall
nut employ any person in any manner so as to become subject to the Workers'
PAID
Corapensationlawsof California Dna
WATER SYSTEbhTREATING
Date Rccciptp
Applicant
NOTICEID APPLICANT: If. after making this Certificart Exemption. you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
becmne subject m the Wmkeea Compensation provision of the Latham Code, you Cont
foodwith comply with such provisions or this permit shill be dccmcdrevoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which his amain is issued (Sec. 3(191, Civ. C.)
TOTAL:
ELECTRIC FEE
lender's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I canny shot I have read this application end stale thin the chose information is
rect. l agree to comply with all city and county ordinances and sate laws relating to
PERMIT ISSUANCE
MECHANICAL. FEE
building construction, and hereby authorize representatives of thiscity to enter upon the
alcove -mentioned progeny for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (1-0 10,000 CFM)
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Hishilitic,judgmem,coss se dexpenvvit It may in any we accrue against said City
AIR HANDLING UNIT (OVER IBM CFM)
PAID
in co m of the grant 6 of Nis trait.
7_/d�
of Applicamt/Con m Date
EXIIAUSTHOOD(W/DUCO
HEATING UNIT(TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Rcccipt t
HEATING UNIT (OVER 100,000 BTU)
IDT
Will the applicant or future building occupant sore or handle hmardous material
as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety
VENT ELATION PAN (SINGLE RFS ID)
Code. Section 21532(a)1
❑ Yes ❑ No
ISSUANCE DA 'E
BOILER-COMPUHPOR IW,O(NIBTU)
BOILER - COMP(OVER IW,t1W B'rU)
Will tbcapplicantnrfumrebuildingoccupunt usecyuipmcmordeviceswhichemit
hvurdous air contaminants as defined by the Bay Area Air Quality Management
PAID
Dkhricff
NEW RESIDENTIAL MECH.—SQ. FT.
❑ Yes ❑ No
1 have sad the hvarde., materials "ttixmems under Chapter 6.95 of the
JUL 1
AR
California I ealth & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ilthe building Ates nm currcmly have a tenant. that it is my responsibility to notify the
cecupant of the requirements which mut be ma prior m i,svance of a Cenificete of
Is. Y Uf OF GI t$
Occupancy.
177
ISSUED BY:
Owner or authotized agent Date
TOTAL:
OFFICE