28418 (2) II APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE'RTINO BUILDING-EILF.CI RICAL PERM]I'N(1
BUILDING DIVISION 28418
1 H�1 1 H
APPLICATION/PERMIT PLUNIRING-MECHANICAL. L
BUILDING PROTECT IDENTIFICATION
IIUILDING pDo OLS � UNIT of LOTq SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS L1MF.: PHONE: C N'TRACTOR'9 NAM13: LIC NO, Cal
ll�fl oar C1 r N/C COM ROLM
NRCHITECEINGINEER: O( LIC INO: `C ADDRESS: ❑ -70
OMACI'. a PHONE: BUILDING PERMIT INF
(` n H��+ *�I9P I�Z n rig
Q I'Y. ELECTRIC PERMIT FEE
vV��l'7 ryRAC �/C _1X16 BLDG ELIi I'LU MliCll
PERMIT ISSUANCE
LICA;NSEUCONTRAGTOR'SDGCLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPI]ON
WOO Iher2hya Divi,ml3 ofth Bmiiled n,,rero xocesCo e, (m ingwiN
FOO Section 7lrnal ff Division Jof the Business and Pralcssions Cole,and my license is in pANGLS
p'' full maternal egecO I� yv�■V\I
LQ.," 1-Leen-Clara LiaH UP TO 200 AMPS
y Q y Ilam Comna ror 201-HIM AMPS
F�q'j ARCHITECTS DECLARATION —/ SQ.FT.FL
zo�— OVER 1000 AMPS ARE
�J]\
IT.
Oz_MI understand my shM1 ll be used as public mounds.
rnF'uSIGNS ELECTRICAL
Licensed lkabssionul eiz ^1L
�Owu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO ex, I hereby affirm that 1 um exempt from the Contractor's License Law for the
/l+]31r.y lidlowing mtxonSection 90315,Ruxinceand Professions Codr:Any eitymemunty TEMP.
which requires m construct,alter,improve,demolish,or repair any structure TBMP.MEIER OR POLE INS].
' yam
waE
-
prior m it, mntt,afrorcquimstheapplica,fimuah r to fileasignedstmcmerl POWER DEVICES
�LLKOO that he is licensed pursuanuo the provisions uftbc Contractor a License Law(Ch:gner
�LLOio� 9(commcncing with Section 7000)of Division 3 oclhe Business and PmfessionS Cale) SWIMMING POOL ELECBIC _ VALUATION
W22w or that he is exempt therefrom and the basis for the alleged exemption.Any violation o'4 /�
F-Za
Section by any applicant for pmmtil subjects the applicant to a civil penalty of OCI'LITS-SWITCHES-PI%"RIHES .O/ ��
ria more than five hundred dollars($5110). (
L' � ❑ Lasmwnerofthe prope ny,ormycmpIoyees with wn esu lheirsolecom pcnsutio , NEW RFSIDENTIALE1.13CR —SQ,Ffl`.
STORI' R TYPE CONSTHUCr10N
( y3= willdo the work,and the svuaure isnot imendedoroffered for sale(Sec.]044,Business
and Profesinas C,Aaa The Caroanor's License Lou,does mu apply m an owner of rNJ,
property who buildsor improves thereon,an([whodoes such work himself orthrough his lt-
rm ^ OCC.GRO Q . RFS.UNITS
rwnemployees,providedthat such improvees:uenot intendNoroffered hostile.if, lr J 1
however,the building or improvement is sold within one year of eomplelion,the owner-
builderwilihavc fhv hurdmorproving lhm be did nnf build or improve for for,so-of OT i
mlc.). Hr
❑ Las owner ofthe propmy,am exclusivelycommaing with licensedmnuaams to QTY. BING PERMIT FEE ROOD ZONIi a� APN
rmuun the project(Sec.71W,Baronce and Professions Cutlet The Contractor's
I hearse Law does not apply loan ownernfpropnywhnbuildsorimprovesthercon,unJ PERM[I1Q9UANC&C
Lraforsuch project withacommctmr(s)liccnud pursuanuothe Comranor's
License cense Law.
ALTF. -D I AV TER(EA) FEE SUMMARY
❑ 1 am exempt under Sec ,li&P C for this rcuson If
BACK RO OT .DEVICE OU'I'SIDI:ZEES
SANITARY Y N
Owner Dore DRAINS-FLOO ,R COND. RECHIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
PER DROP❑ Ihcmhy affimuhuflhave ncenificnrcol consent to self-insure.oraceruficam of FIXTURES- C a
WorkersCompensation Insurance or acetified copy Ncrod(Sec.3800,Lab C.)which PARK FEE
covers all employee's under Nis permit. GAS-I:A.SYSTEM-1 INC.40UI'LETS ECI3I rM
policy us BUIL 1 IVI. ONFBIS
Company GAS-EA.SYSTEM OVER 41EA) PLANCHECK PEE
❑ Cenlfied copy is hereby famished.
❑ CenlficJ copy is filed withthe city inspection division. GREASEONDUS'TRL WASTE INTERCEPTOR GRADING[iE]: 'rte
CERT119CATE OF EXEMPT ION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE.
( (This section need not be completed ifthe permit is for one hundred dollars 01100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less,)
I ccnify that in the perfomtwu of Ne work fur which Nix permit is issued.l shall WATER HEATER W/VFNTlELECfR
not employ any tenon in any manner m as ,,become subject to the worker' PAID
Compensation LawSofCallforllfa. Date WATERSYS'TEM/CREATING Data eelpt#
Q z Applicant
zO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. T TAL:
become subject o the Workers Compensation provisions of fire Labor Gsle,you must
7 flvthwiN comply with such IF visinm or this pemfil shop be dammed revoked. BUILDING ITE —
1 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm than there is a consfmnion lending agency for the Performance of ELECTRIC HE
L) Q the work for which this permit is issued(Sec.3097,Civ,CJ �•
F
Lender's Name PLUMBING FEE
O Lenders Address QTY. MECHANICAL PERMIT' FEF;
U I ccnify'hot I have read thus applicafioo and xmm Nat the above Information is
F UJ correct.I agree to comply with all city and county ordinances and sm¢1xao relating to PERMIT ISSUANCE '� MF,CHANICAf.F[E
buildingconsuunron,and hereby authoduapmsematives of lhiscitymen¢r upon the
L) z above mentioned propmy for inspection purposes. ALI RR OR ADD TO MHCH. CONSTRUCTION TA%
(We)agree to some,indemnify and keep harmless the City of Cupertino against
livbilitin,judgmems.costs aadex
s ichmay inany say.,meany way.,me said City AIR HANDLINGDLING UNIT(TO 10.004)CFM)
n eon¢prµ of lM1e anringo Thpeis nupe n
�i AIR HANDLING UNIT(OVER 10,000 CFM)
Srgnamm of ApplicanOCom nr _Q Date EXHAUST HOOD(W/DUCq
PAID
IIA%ARDOUS MA'I'13RIALS DISCLOSURE CL
IIEA1'INO UNI'C CTO 100,0f BTU) Date Receipt N
Will the applicant or future building acupant smm or hurdle baazrAom material HEATING UNI'1'(OVER i00,000 BE T
as defined by the Cuprti
eno Municipal Cede.CTapmr 9.12,and the Health and Safety
Cuts.Se i255i2pp] rl
VENTILATION PAN(SINGLE RSiID1
❑Yrs ❑N ISSUANCE DATE
WilhMa Iiwm orfumrebuiliin tuecc 'pmrn BOILER-COME LEHP OR I M,OW BTU)
ca dby'he ye muality o�wbichemn
Imrardouh air amtaminantn as Jefrmd by the Buy Area Air Quality Munagemcnl BOILER-COMP(OVER IW.000 tl'fU)
District?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT.
1 have read the hmmdvus materials requirements under C1kVmr 6.95 of the
California Health&Safety Calc.Sections 25505,25533 and 25534. 1 understand Ihat
ifthebuildinge mgnotcurrently haveatenant,etit is my issuance
of
to notify the
occupant or the requiranems which ravel M mel prior to issuance of a Cenificme of
Occupancy.
Owneror anihmized agent nate "1' ISSUEDB
�d
OFFICE