28184 (2) r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY 1 \
CITY OF CUPERTINO IIUMBING-MECIHANICA-
APPLICATION/PERMIT PING PRNO-SIRCHANICAL L
BUILDINf.DIVISION BUILDING PRO.IRCIIDF:N'1'IF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITl'AL DA'1'1:
RE
0 row Q9XUNIT# LOT#
' N H. �11y1�l, kPONT TO AM ► CM LIC NO: \
�fl C,"L\+Ul^.f/� NBC CONTROL#—
�RCl11TIiCr/IiNG1NEliR: LIC NO'. AflDR155: ❑
CONTACT: PI1(1NE: QTY. ELECTRIC PERMIT' EEE BUILDING PERMIT INFO J
BI.OG E PL M-ECH
PERMIT ISSUANCE /' \ITT
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBDISCRIPIION
owy Ihemby affiliation lam licenscdiader provisivasofarpher9(commtram,with
ltJ00 Seedon700(imf Division 3 of the Bavinesv and Pnd¢vsiom Code,andmyl lcenm is in PANELS W�--
yVF frllforceardeffecl. UP TO 20D AMPS w
FQy� License Class Lic#
ydo• Dam Co ahator 201-IOW AMPS
F-yZ ARCIII'I ELTS DECLARATION SQ.FL FLOOR AREA $/SQ.FT.
yOm— Iunderstandm hdl be used as public necords. OVER 11%MIAMPS
py—p my
OZ-0 SIGNS I;LECTRICAI. sco
(t
Qid Licensed Professional
�yecd OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. _
5a5�0yF I hereby affirm that 1 am exempt from the Contractor's License Law for IM1e ^
N:e,zi following maxim.ISect..a 70115,Business.6 Professions Code:Any city.,county TEMP.MEI ER OR POL1i 1NST. �Z� LO
F�'0 which miluires a pe.it t.cooapun,alteq impmvn,demolish,or repair any cometum
d Was to its issuance,al,atrc the applicant for such In file a signed slatemmt POWER DFVICGS
prior 4uircs PP cermil gat
Y that he is licensed pursuant to the provisions of the Comruanr's License Law(Chapter
tie.Q 9commencin )of Division 3 of the Business had Professions,Code SWIMMING POOL ELECTRIC 2 VALUATION
(commencing arefon]OW )
ad
Sectio 7031 by
ertfmmnt for a bmisronbeallcgedeaemptt to Anyl Pena.n of OUTLETS-SWITCHES-
5Fa not
mom than
iv hundmlicanlrs Won). mbjecu IM1e applicant toucivil penalty of FIXTURES `
WL: not mLanownrofthedmddollarsyemp. NEW RFSIDENTIALELECFR SQ.FT.
�F_p ❑ I,¢wwncmfthe proceny.ormyempinyeeswitM1 wages as theirsulecomµnsation, STORIES TYPE CONSTRUCTION
atal
will do the wofk,and thestn:chn,is not intended.luffered for sale(See,7044,Business 4
O
and Professions Code:The Contncctors License Law does not apply to an owner of
pint who builds or improves thereon,and who does such work himselfor through his
ownear,doye,f, for sales If, OCC.GROUP RES.UNITS
however,the building o,improvement is sold within one ycarofcompletion,IM1e owner- O"AL.
BT-
builder will have the burden of proving that he did not build or improve for purpose,of
�uas owns of the procerty,nnusinss an contracting licensed Contractontractors or's
QTY. PLUMBING PERMIT FEE FLOODZONE APN
trues the pmjttt(Sec.]tM4.Business and Pmfcxsiws Cock)The Comrwmr's
License Law A.esnmupply to un nwnewfpmµrty who bulldsmimproves thcmon.and PBRMI'I'ISSUANCE
Docase Lmv.fm such pmjtttawithacontructor(s)IiccnseJ punuanuolM1e Convuctor's ALTER-DRAIN&VENT-WATER BEA) FEE SUMMARY
Licensenn e.
❑ 1 nm exon under Scc. B&P C for this reason BACK FLOW PRO'FECI'.DEVICE llTsl tiES
Owner • Uate SANITARY N
DRAINS-FLOOR.ROOP.A ONE, L1 #
W ftKMAN COMPENSA ION DECLARATION SCHOOLTAX N
❑ Ih by alEm that lhaveucenificme tsem lad!-insure.nruccnificam of FIXTURES-PER TRAP .II'fIt
Warom, rope tors hoummemr.ccmGcd copythemo!(Sec.37bC.)whivh PARK PtiE N
if
nallem ee'a under this Ictal. GAS-IIA.SYSTE-M-1INC.40UTLETS R.CE1n
P.Isy# [LI N IVISIONFEES
Company GAS-EA.SYSTEM-OVER 41 PLANCHE FEF.
C] Certified copy is hereby furnished. a
❑ Certified copy is file]with the city in.vpcdion division. GREASIONDUS'FRL WASTE INT eRCEP R GRADIN �'•
CERTIFICATE 01:EXEMPTION FROM ORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURAN ?
(This section need not be completed ifthe permit is ronehundred I 5 W) tWER-SANITARY-STORM EA.2WIr1'. ENERGY FEE
or lws.)
IcenifytM1slintheµrfotnnncenflhework f hichlhisµnni "s shall WATER IIFATF.R WNENT/ELECTR
not employ say cenon in any mm�ncr so as become subjem t I orke ' PAID
Compenmtion Lawsof Calimmu. Dam WATER SYSTEM/TREATING Date R eipl#
O z Applicant 41
Z 0 NOTICE TO APPLICANT:ILafrr making t Cmifieamof Eae a ,you sh uld NEWRESIDF,NI'IALPLMB. SQ.FT. TOTAL:
f" rte. beemne,abjeelmlhe Workers Cotrigam ionp ,sons of@eU c,yo ust
a 7 fnnM1with mately with sucM1 provisions or Thisµ itlshallbedeentedrc d. BUILDING FY;Ii V ��
1 Q CONSTRUCTION LENDIN GENCY�: SEISMIC PHIi
7 z 1 hereby affirm that them is a conswclam lendinb gency for the perfo ee of Q Q
UO Weworkfor which thisµrmit isissued(Sec.3(n].Civ. 'O F.LECfRICFEE
Lenders Nmrni PLUMBING FEE
u' F Lender's Address QTY. MECHANICAL PERMIT FEE
0 U I ce"d,that 1 have read Thi,application and state Ihot IM1e n e inf mtinn is MGCI IANICAL FEE comcct.lagrc<lo comply with all<iy and cnumy oNinanccx and nhv w on lo PERMIT ISSUANCE
building construction,and hereby authorize mprosenmtives ofthis city to c ruponthe CONSTRUCFIONTA%
U Z above"mchnorad pnptcny I.,insltcnion purp.sea. ALTIiR OR ADD TO MECfI.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabil'tics,judgmcros,costs and expenses which may in any way accmeagainst said City AIR HANDLING UNIT(TO 10,000 CFNU
in conseq�nce f be;andin,ol'this �.r��la �'��Qr`� AIR HANDLING UNIT(OVER IO,W)CFM) w
/���Viya- '{l1
Sigarc of A qJi ant/Comosonr Dom EXHAUST HOOD(W/DUCI PAID
HAZARDOUS MATT IALS DISCLOSURE HEATING UNIT(TO IW.000 BTU) Date Heccipt
#
uupplicam or future building occupant store or handle hazufdous materialHEATING UNI'I'(OVIiR 100.000 BTU] TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health road Safety
Code,Section 25532(a)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE,
Will theapplicantarfummbuildingeecupnat ueeequipmemordevices which emit BOILER-COMP(3HP OR 100,000 BTU) a� _
` hamN.us air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVLR IW,WO BTU)
District? El RESIDENTIALNOV 15 1999
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous mamrih6 requirement under Chapter 6.95 of the C1
1 Y Uh
Califomia Ifealth&Safety Code,Sections 25505,25533 and 25534. I understand that UUr[rI 1 hVU
if the building does not cumntly have a tenant,that it is my responsibility to notify the
.ccup:un m the requirements which must sc met prior 1.iswance of a Certificate of
Occupancy.
Owners authorill agent Dam O ISSl11?D BY: '
OFFICE