28180 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N U.DL2V11NG-RLE,I'RICAI, PERMITNO. 1 8 O
APPLICATION/PERMIT PLUMBING-MECHANICAL L
]BUILDING DIVISION BUILDING PROJECT HJEV'I WICATTON
BUILDING ADDRESS: I SANITARY NO. APPLICATION
ICATOON SUBMITTAL DA'TE
LOS • '/G/ttiI UNIT# LOT# 4! O ^��
UW RNA PI QN��� ..X CO TRS"1'OR'S Ngh)G: � LIOC ryQ: N/C CONTROL#
'•ANCIII'I IiC'1'/ENG E13R: LIC NO: / ADDRESS/S: tLflGGlpl [(l
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARA'T'ION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ I hereby effort tom luta licenxJ under provisitnsofCTapmr9(commevcing with
4100 Section7000fof Division3uf the Businexsund Pmfessions Code,and my license is in PANELS �Q
ERIC lulllnnClass act JZSh -C-Eta14IEsVr
a- �JJ License Class Licx� 21'-1200 AMPS
W. Umc C'"ntTSD �� 2111-IUIXIAMI'S SQ.Ff.FLUOR AREA S/SQ.FT.
F y,t CHITIiCI'S UECLARATIO OVER]Bob AMPS
Z 0 oe— I understand my plans shall be used as public records.
0 m F Pit SIGNS ELECTRICAL
Qy2J I,ittnsW Profcssiond
oea OWNER.BUILDER DECLARATION SPECIAL CIRCUITIMISC.
1 O a V L hereby affirm thus 1 am exempt from the Caron h License Law for the
following rcasort(Section]031.5.Business and Professions Code:Any city or county TEMP.ML-1'Eft OR POLE INST.
T_a:0 a which mquircs a Tamil to corcorum,alter,improve,demolish,or repair any structure
C,Q2 prior to its issuance,also requin,"la,applicantfor such pemlilto file a signed statement POWER DEVICES
for.,he is licensed pursuant o the Provisions 0f Ue Contmctol's License I,aw(Chapter
SWIMMING POOL ELECTRIC
Lyp 9(cnnmcnoing with Section 7000)Of Division3nfthe Businexsund Profcssiare Ctdm) VAL.UA'TION
or That he is exempt homrrma and the basis for the alleged exemption.Any violation Of OUTLETS-SWITCHPS-FIXTURES
F'LQSection 7031.5 by any applicantfor.permit subjects the applicmn 10 a civil penalty Of
ESDtmam than five hundred dollum(S5Wk NEW RESIDI:N"IIAL ELECTS SQ.FT.
1'Fo n❑ 1.a<ownerofthepropcny,ormycmploycuwithwagcsasthcironnlecompensation, STORIES TYPECONSTRUCTION
will dothework.aod the strucmm is not intendedoroffered Intrude(Sm.]044,Busioas
and Professions Cale:The Commossmfs Limme Law does not apply to an owner of
props ny who bu ilds Or improves thereon,and who does such work hi mse l f or thm.gh his
cmployms,pmvidedthm such improvetnemsare notimenJNor offcrtdforsale.If OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden Of proving that M1e did not build or improve fur purpose of
sale.)' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Iuct Owner tithproject
(See.704:mmxcluaicclnd Professions
O ole:)sedTh contractors to
License
the prrinal(Sec.to an
ncrofss and Profession Calc:)The Conthereon,
herm,and
License Lvw Joesnot apply mun nwncnd prupeny wM1obuilds or improves thereon,and PIiRMI'I'ISSUANCE
eche contracts forsuch projects with a ammcmgs)licensed purs..nt or the Contmctors
License Law. ALTER-DRAIN&VENT-WATCft BEAT FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEV IC O IDL LLS
SANITARY Y N
• Owner Date DRAINS-FLOOR.ROOF EA.GOND. RECEII'Pp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affirm that)have ucenifcae of consent In xlf-insure,ora cenifcate of FIXTURES-PER P RECEUvp#
Workers'Compensation lnwmnce or v minified copy thereof(Sm.3800,Lab C.)which PARK FEE Y N
, -
RECEIPT#
FEESPlcrx allcm I yo,Rt ipai, GAS BUILDING]AVISION
oiy x h STEM-1 INC.4OUT'LET S
CoI pun) 6 AS-EA.SYSTEM-OVER 4THAT PLANC2ECK FEE
X Cenincdm"pyisherebymndahm.
❑ Cenifed copy is fled with tM1e city inspection division. GREASE./INDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This acciionnced notb,exurpincd ifflepermit is for one handmaid"II (SEW) SEWER-SANITARY-ST MEA.201 IfNITRGYfME
or less.)
I cenifythut inthc orfommnce 0fthe work for which this permit is ions. .l shall WA'IERH;ATE W 'Lh:CIR w
non nemploy any ..... in any manner.o as m become srtbjecr nt the eskers P ID
Compcnsaion Luws of Calilornin. Date THRKyy G Date Receipt x
O2 Applicant
0 NO'T'ICE TO APPLICANT:ILufterntaking this Certificate Of Exemption,you so uld 1 LPL .IT. TOTAL:
f" l/J become subject to the Workds Compensation provisions of the Labor Code.you in st
forthwith comply with such provisions or this permit shall he deemed revoked. T BUILDING FEE
R
Cl1 QSEISMIC FEE
t1 CONSTRUCTION LENDING AGENCY
U
I hereby affirm thatthem is a construction lending agency for the perfmrmance of 2TOTAL: EI.ECfRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's N.me PLUMBING FEE
Lender's Acidmss Q MECHANI , F,RMIT FEE
0 U I certify thin 1 have road this application and state that the mase information is
>'^ W comet.lugrmem comply with all city andcnom,moinances and state haws relating to PERMI'1'ISSl1AN O-� MECHANICAL ELB
F N buildingco.....coon,andl,"byauthorirercprtsemelivcs Ol Wixcity to en ter upon the CONST RUCTION TAX
V 'z uMwcrentioned property for inspection purposes. _HR OR TO MSCI{.
(We)agree to save,indemnify and keep harmless the City,,(Cupenin0 against
liabilities,yj(udgmere,enstsand expenseswhich may in any way somme.gainatxnid City AIR I DUNG UNIT(TO 10.000 CEM)
in cunsegt �A1ce of(M1e gran1in fl fix pCsmil. � ` /
AIR HANDLING UNIT(OVER 10.00)CFM)
Signature of ApPlicant/Contrucmr ID.m EXIIAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Da OF
Will the applicant Or future building tamupant store or handle To...odmis material 'TOTAL:
is deMN by the Cupertino Municipal Code,Chapter 9.12,amd the Ileuhh and Safety
HEATING UNIT(OVER 100,fxq R'1'l1)
Cn to,Section 25532(.)'! � - VLiNTILATION FAN(SINGLE RES HE
❑Yes Y4 Nn
/ _e BOILIiN-COMP(3HPOR 100.0001{]'U) t ISSUANCE DATE
Will the acontamonts outodefiroad by the Bay equip menmuality Management
P A P, L{.
havudous air contaminants ss defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 B'I'U)
District?
❑Yes �TIJ NEW RESIDENTIAL MECH. SQ.tT.
1 have read the hasmdom materials requirements under CTapter 6.95 of the JUN 3 0 1995
California Ilealth&Safety Code,Sections 25505,25533 and 25534. 1 understand that
If the building docs not currently have a temmt,that it is my respsnsihility t"notify the
em.p.Itt or me regmrementx whlmh Immo lc aroma pda ro 1xa.Itmme m'a Ceniye to rtf I I Y Ur t,ur ' I IINU
(kcupancy
Use er Orauth0riudagent Dae 'TOTAL: ISSUIiU /
OFFICE