28161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY �
CITY OF CUPERTINOt 1.)IN s-ELT.—IRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�O
BUII,IIING DIVISION BUILDING PROJECT IDENTIFICATION L o
161
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTALfigDATE
OWR=NApy
O \`e a, %j 11-1a, ��AI1�V rM UNIT It LOT p LIC NO: V
�1�
CONTRA R'SN E:
SF NIC CONTROLM
' ARCHII'ICCT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BI PLUMB MF,CH
PI?RMIT ISSUANCIi
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p y,Z Ihereby air.thin lam licensedmrds,amsimars of Chaptar9(commando,with JOB DESCRIPTION
JU00 Section]0(0)of Division 3 of the Business and I'immoiom Code,and my license is in PANELS � x
C W full force and effect
<_ License Class LIC.# UP'T0200 AMPS W
Lo<s Dae Contemn, 201-IOW AMPS
E—=Z ARCHITECTS DECLARATION SQ.IT.MOOR AREA S/SQ•FT.
CA
ZOrn-
1uMerswnd my plans shallpublicTIOVER 1000AMPS
OG-0
F y F W SIGNS ELECTRICAL
<yf'J Licensed Professional
y PdR OWNER-Bempt front
RDIthe CantTION SPECIAL CIRCUD'/MISC.
W ci 1 nmehy n.(Se tits n,exempt from the Cantons Code:
License law co the
,a:0y following names(Section]11JL5,Business and Professions GNe:Any city or county TI3MP.METER OR POLE INST.
F�-0 which reclaims a Permit to construct.alter,improve,demolish,or repair any structureS YS la its issuance.alsorc res the applicant for such lto file a signed statement POWER DEVICES
G prior tto pp Pmol gn
Ina he is licensed pursuant to the previsions of the Contractor's License Law(Chapter VALUATION
4F: 9 with Section RKKJl of Division 3 ofthe Business and Professions Code) SWIMMING PoOI.ELECTRIC
(commehat he ncing
WZ Settion701.5 by my
the beaky^nnects the exemption civil lmion of OUTLETS-SW11CHES- q
F-ZQ no,Section 7031.5 hu applicant EV500)nit subjects the npPlicanuoacivil penalty of FIXTURES O �V
gy=p tmerc Chun five hundred dollars(5500). NEWRIESIDENTIALELECIR _SQ.PT. STORIES (/ TYPECONSTRUCTION
yF� m❑ I,mowncrofthepropcay,ormyemployeeswiNwagesmthcirsolecompemetion.
y3_ will do the work,and the structure is not intended or offered for mile(See.7W.Business
and Prsdesdom Code:The Contractors License Law does not apply to an owner of
properly who builds or Improves Ihercon,und whodoes such work himsel for through his
empl^yces,powided that such improvementsme not i,cnJedorsdfered fermle.If, UCC.GROUP EAPN
IS
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build m improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE A
I ❑ I,mnwnernOM1e prolertY•sm exclusively convanin&with licensed sato-ammo IBOU LONE
instruct the project(See.0144,Business and From n,Cmle:)'Me Cmamelial
hiceme Luw Jocs not apply mannwnerofpropeny why builds nrimpraves thereon,and PERMITISSUANCE
whosom ucts forsuch projects with aconmtctm(e)licensed pursuant to the Coman,ors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um<mmpt under Sec. ,tl&P C for IM1is mason BACK FLOW PROTECT.DEVICEOUT I L ES
SANITARY YN
Owner Dae DRAINS-FLOOR.ROOF,AREA,COND. RPCHlPT#
WORKMAN COMPENSATION DECLARATION SCHOOL FAX YN
❑ Inercby affirm thetl have a<ertificam of conunum ulGinsurc,ora cenificae of pl%TURFS-PIiR'rItAP RECEIPT#
Weakest'Compensation lnsueareeor a ccnifiedeopy lherem(Sec.3803.Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-FA.SYSTMM.I INCA OU TS RECEIPT#
Policy p BUILDING UI VISION FEES
Company GAS-EA.SYS'I'HM OYF, 4 PLANCHECK FEE
❑ Certified copy,is hereby famished.
❑ Cenified copy is Bled with the city inspaalom division. GREASIVINDUSTRL WASTIMF C OR GNADING h:F
CERTTFICATIE OF EXEMPTION FROM WORKERS' GRFA$ TRAP SO 1.13
COMPENSATION INSURANCE
(Da,wction recision,Beemapletedlithe pmmitisfor onehundreddollars(SIIX1) SEWER- N Y- R EA.200FT. 12NERs I:H
los.)
I ceirlylhat in the performance of the work for which thispermit is issued,I shall WATER W/VENDELECfR
std employ any paean in any roamer m m became subject to the Worker' PAID
Coope^mtionlawsmColifomia. Date so WATER SYS EATING Date Rmci,#
Zz APpliwm
C1 NO[ICI?TO APPLICANT:if after makinglhis Cenificamof Exemption.yna.hould NEW RESIDENTIAL PLMB. SQ.FT TOTAL:
^ become ampinathc Worker's Compensation provisions of the Labor Code,younmst
� > forthwith comply with such Provisions or this permit shall he deemed revoked. BUILDING PEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEL?
z Ihereby affirm that them is a conswaion lending agency for the performance of TOTAL: IiLECfRIC FEE
V 5 the work for which this pernm is issued(Sec.9097,Civ.C.)
1;z
Lender's Name PLUMBING FEE
D-' F Under'a Address QTY. MECHANICAL PERMIT FEE
V I really the 1 have mad this application and sate ram Inc above inf-somim is MECHANICAL FEE
W comma.l agree to comply with all city and county ordinances and nam laws relating to PERMIT ISSUANCE
h• aM building nmnrurtlon,and hereby mormre representatives ofthis city to enter open the CONSTRUCHONTAX
Uanmve-oentioned property for inspection purposes. AL MR OR ADD TO MECH.
(We)agree m are,'mden,i fy and keep hmmlcss the City of Cupemino against
inC.itim,judgmcnn,coas anti expenses which ma ' yway ccmcagain miiJ AIR HANDLING UNIT(TO I),(W CFM)
e gmntingpf this pe
AIR HANDLING UNIT(OVER IO,gp CFM)
ignaurco Applicant/C^mractnr Dat, 17XIIAUST HOOD(W/DUCT)
PAID
HAZARDOUS MAI ERIAIS DISCLOSURE 1117ATING USE F('I 0100.000BTU) Datc Rccci t#
Will the applicant or future building Occupant slam or handle ha rmolous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety THAT
UNIT(OVER IM."BTU) T Lo
Cade,Seaton 25532(alp
❑Yes ❑No VENTILATION PAN(SINGLE RESIDE
ISSUANCE DATE
Will the affliction Or fumrebuildingoccupanl uaequipmem ordevices which emit BOILER-COME'LIMP OR 100.00 BTU) Pha,mous air comaminmb as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0110 BTU))
Dixtriml 0
13 Yes ❑No NEW RESIDENI'IAI.MECH.—SQ.FT.
1 have read the husallous materials rcyuircments under Chapter 6.95 or the
if ie buil i n g does of etycur a nMq have
m 25505,25533 titisy responad sibility
I undemand lits a�jY(!h 19,95
cerhebuildingacesnocurrentlyich atens,,that itis my rcspomibf. ermthlythe
^ccapent of the rcquimmenla which man be met pains to iaeu.nce of a Certificate of ��~�H
arawnry.
owner nr umhoiuJ
an Dust IDEA].: ISSUED BY
OFFICE