26081 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT No. O
APPLICATION/PERMIT DINGPLUPROD MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
B81
UILDING ADDRESS: SANITARY NO, APPLICATIONSUBMITTALDATE
P. C-L-e�A� a C. LOT» r31-�t�-P
OW RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
O
WC CONTROL#
CHITEC /E GINEER: LIC NO: ADD ESS: � ❑
CONTACT: PHGN�4E: BUILDING PERMIT INFO
/'�JJ QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
-PI PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Om2, Ihereby 0).1'rmrhmi amlicensed Buinessard Ponfiesions Corsa((commencing with
�i100 Section far eBOB)ef Division Ne Business end Rofeseions Code.and my liceaae is in ppNBls `�ISf�vT Ge- p ,f
License
Class-fleet rl 4a` Vn
�yy Licena<Class Lie.#,
IIP T0200AMPS
rTi,?y Dale Conuacu� 201.10110AMPS M's P/Jr�Q�" NVst
2.O riys� ARCt11TECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.En
O Z•-•q 1 understand my plans shell be used as public records.
rK�'w SIGNS ELECTRICAL
G,g,�j .1 Lm-aised Profesawnal
C ¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUTI/MTSC.
30.E 1 hereby affirm that 1 em exempt from the Conferences License Law for thefinhev _
O rr which ing reawa permit
to construct,
t,slows said improve,
de Professions Code.Any cityor county TEMP.METER OR PoLE(NST.
2, 7 which requires a pertnh ne construct,plea improve,demolish,ore a sir any swttme
Q� that heor s issuance,foramen
th the visions of
fthe Conetmino filLice signed stamina.. POWER DEVICES
i LL O p
that he is licensed pumunnt m the provisions of the Contactors License Law(Chapter .1
0.pP4 9(commercing with Section 7000)of Division 3o17the Businessand Professions Code) SWIMMING POOLE IC .I _ VALUATION
W..m or that he is exempt hmarrom said the basis for the alleged exemption.Any violation of S
OUTLET -S HES-pr=
r Senion]031.5 by any applicant for a permit subjects the applicanno a civil prnAry of �-� 1 V
0 not more Man five hundred dollars($500). (--
❑ I,asownerofthepmo M,ormyempinyeeswiMwgesestheirsoleempensaion, NEW RPSAL ELECfR STORIES TYPE CONSTRUCTION
y will do the work,and thesuumure isnotintended oroffered Reside(Sm.7W,Business /.I
and Professions Code:no Contracmr's License Law does not apply to an owner of
property who builds m improves[be...and who does such work himaelfor through his
employees,providedthatsuchimprovementsmenotintendedaroffosiforse le.If, OCC.GROUP RES.UNITS
however,the building or impervement is sold within one year of completion,the owner-
builder will have the burden ofproving that he did not build or improve for purpose of TOTAL:
sale.).
❑ Las ownerot thepropeny,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
carawct the project(Sec.7044,Business and Professions Code:)The Courtrai
License Law does not apply to an owner ofpropcny who builds or improves thereon,and PERMIT ISSUANCE
whocantracts for such projects with a co musetm(s)licensed pursuant to the Condraclor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
❑ 1 am exempt under Sec. ,B&P C fin this reason
Owner BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Date R
ROOF.,AREA,COND. ECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS- SCHOOL TAX YN
(hereby aTI
ffirm that l have a eactifcite of consent to sel6insure,or a certificate of
rkerFIXTURES-PER TRAP RECEIPT#
s'Compensation Insurance or a certified copy thereof 380.Lab C.)which PARK FEE Y—N
—
Policy
el l employee's lard., per
nder this mit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
#Company BUILDING DIVISION FES
[3Certified copy ie hereby famished.aGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ C
Cenified copy is riled with the city inspection division. GREASEIINDUSTRL WASTE INXCEFTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASRTRAP SOILS FEE
COMPENSATION INSURANCE
(This section mormtbovempleted ifthe partial is foronehundred dollars($100) SEWER-SANITARY- ORM EA.20(PT. ENERGY FEB
orless.)
I cattily that in the perfomance of the work for which this permit is mated,Ishell WATER HEATER /VENTIELECTR
not employ any person in any manner so as to become subject to the Workers PAID
,z Compensation Ltwsof Califomia. Data WATER SYR RENTING Date Receipt#
C z Applicant
NOTICE TO APPLICANT:If,after making this Certifdcem of Exemption,you should NEW:?DENTAL PUMP. SQ.ET. TOTAL:
GC become subject to the Worker's Compem"i-'Q.—sionsofthe Labor Code,yav must
Ills^^^ forthwith comply with such provisions m this Iflnnit shAl be decmed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of
L) the work for Which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
(•kaLenders Name -
O U Landes Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that I have read this application and state that the above information is MECHANICAL FEE
correct l agree m comply with ell city and co only eminences and slate laws relining to PERMIT ISSUANCE
y building construction,and hereby authodu representativeso(this city to enter upon the
V Z above-mentioned property for inspection puryoses. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmleas the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO I It"CFM)
to cement encs of the Rending of this permit.
•/(��ae(_]l,/�,, LAIR HANDLING UNIT(OVER Io,000 CFM)
Y Signator- I'ApplicanVContector - A EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00p BTU) Dam Receipt#
Will the applicant on future building occupant store or handle hazardous materiel HEATING UNIT(OVER 1 W,000 BT
as defined by the Carcinoma Municipal Code,Chapter 9.12,and the Health and Safety T TA
Code,Seen..25532(
11 Yes ❑No VENTILATION
VENAON FAN(SINGLE SID)
BOILER-COME(3HP ORI .000 BTU) ISSUANCE DATE
Will this committeaurn es
s as building by the Day Areequa Aent Quality
eswhicheam P urs I D
a,[net?s air cnntsmirunts az defined by the Bey Area Air Queliry Managemem BOILER-COMP(OV W,000 BTU) iv yR
'strict]
❑Yes ❑No NEW RESIDENT( PCH. $Q.ET. MAY 31
I have read the hazardous materials requirements under Chapter 6.95 of the 1994
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand Med ���Ur
iR aparn of the res not quirements
nts ly whicve a h
must Is, thmriort is my reuance ility m ifi; the l,Uf Cry l fly
Occup an of the ray mems which must be metprior to issuance of e C rtificate of
Occupancy. ]N
Owner aur amhorize gem Dam TOTAL: ISSUED BY:
OFFICE