28188 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOl8J HUILDIN's-F,LRCI'RICAL PERMITNO. Aar
APPLICATION/PERMIT PLUM III N;-MECHANICAL -2 8l8
BUILDING DIVISION BUILDING PROJECT IDEMI'IFICATION
BUILDING ADDRESS: SAN['1 ARY NO. APPLICATION SUIiMI'I'fAL DATE
S� oog c S
UNIT# LOT.
OWrVERS NA ` PHONE: CONTRACFOR'SNAME: LIC NO:
/ !/ NIC CONTROL
RCHIITG fliNGl LIC NO: ADDRESS: ❑
P
CONTACT': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MCCH
-j J �k✓ .l% 3 PERMIT ISSUANCE 'E)�- El El 0
IJCIiSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GC7 Ihend,atlirn,h:h lam licenacei under proviCh
dm— apter9(commencing with IOD DESCRIPTION
WOO Section 0000)...Division3ofthe Business and Pmfeixlmn Code.and my license is in PANELS s
W fall force and effect. S� /_/'
FU LicsUP TO 200 AMPS
ZyI ene Classont
m?H Dm, Contractor 201-1000 AMPS SQ.FT.FLOOR ARBA 1/50.Fr.
FyZ ARCHITECT'S DECLARATION OVER 1000 AMPS
O!—
ZOyD— I understand my plans shall be used as public records.
y F-; SIGNS ELECTRICAL
Q Licensed Prnfexnionul
xotu OWNER-BUILDER,Iard, dfrDECLARATION SPECIAL CIRCUIT/MISC.
KOiU I hereby n.(Se that I am csempr from the Gonion C's c:Any Law for the
E 4 prFi: whichfollmains mama(Section 7031.5.Business and Professions h,or re repair
city or county TEMP.METER OR POLE INST.
_ which requires a permit to conswn,alter,improve,demolish,or repair any soucmm
}5 prior to its ismence,also requires the applicant mrsuch Pvoratto file a signet smmmem POWER DEVICES
Cthan he is licehxed pumaanit)the provisions of the Conarefor s License Law(Chapter
y SWIMMING POOL ELECIRIC
Yy0 Y(commencing with Section 70103)of Uivisionlof the Business and Professiav Code) /y VALUATION
I,Moo moat he ise.aempnherefromand the bmisforthe allegcJexemption.Any violation of
Y FZQ
Section 7WL56 i PP OUTLETS-SWITCHES-FIXTURES YanY epPlicant furepermn wb'=t,s tM1nn licannoacivil.cushy of
f_O not more than five hundred dollars(S50o). NEW RESIDENTIALELF,CRtSQ.FT.
'at ❑ I,asownerofthepropenY.ormyemployeeswithwagcsasrheirsolecompensfio.. STORIES TYPE CONSTRUCTION
will do the work.and thestrocture isnot intendedoroffernt fmisile(Sce.7044,Business
and Rofcxdons Code:The Commnar's Liove,Law docs nut apply to an owner of
prmpeny who bunds arimprovcs rhertnn,and who dress sueM1 wnrkhimsdfnnhmugh hla OCC.GROUP RES.UNITS
ems,p
ployeerovidedthat,mchimprnvern attiormainm aladorofferedfnrsnla IT
however,the building or improvcmcat is.sold within one yearofcomplcdon.the owner- TOTAL:
builder will have the burden of Proving that he did ned build or improve for purpose of
QTY. PLUMBING PERMIT FEE IT,OOD ZONE MIN
❑ o,1 the er pro(Sce.7044,
04esdus,an PabatingwiC dee)The
e's
..neves the ocsool apply]044,secrof s and Prnfexvions Cade:)Thc Cnnbuanh
license Luwdnasnn,apply tomownensl'.m.erty whobuildsor improve.v thereon,and DI2RMIT ISSUANCh
who contracts for such projects with a contreaor(s)licensed purauam to the Contractor's ALTER-DR &VENT-WATER GiAI FEE SUMMARY
License law.
❑ I nm enempr a See B&P C for this reason BACKv6W PROTECT.DEVICE SIDE FEES
SANITARY Y N
n ate D NS-FLOOR.ROOF,ARFA,COND. RECEIPT#
W RKMANCOMPHNSATIOND' .ARATION SCHOOLTAX Y N
w Ihereby at,'Tsmtum lhavencenilinncolcons"salt,'-imans'nracntilicnm of tl%TURES-PER TRAP RECEIPT#
Leta Compensation Insurance orucenified cupyk mreof(Ser.3g00.LahC)which PARK 19ili Y N
covers all employ='s under this permit. GAS-EA.SYSTEM-I INCA OUTLETS ftECE1PT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHrCK FEE
❑ Ccnifi,deop,ixherebyfumishcd.
❑ Cenificd copy is fled with th<ciry inspection division. GRPASEANDUSTRL WASTE INTER :PI'OR GRADING PER
CHITIFICATE 01'EX EMPTION FROM WORKERS' GRPASETRAP SOILS PHE
COMPENSATION INSURANCE
(This section need not b,completed Unit,permit is forms,hundred dollars($I SEWER- NITAR - A. ENERGY IEE
or less.)
I certify that in performance of the work for which this Permit is issued,I shall WATERH L
not employ any person in nay manner so as to become subject to the WorkersPAID
Compcnsminn Lxwx of Celifornln,
Data WATER SYST RFATING Date Receipt#
zZ Applicant
2 NOIIC1710 APPLICANT ]].after making Mix Ceeificam of Esempoon,y..should NEW RF,SIDENTI ,PLMI Q FF TOTAL:
1-" IA become subject to the Worker's Compenwtion provisions ofthe Labor Coil yo.must �-
� ; molwincrwnply with such provisions ser this permit shall be deemed revoked. BUILDING FEE
0. Q CY CONSTRUCTION LENDING AGENSEISMIC IEE G
1 hcrchy xftimt than there is n.onarunion Innling agency fonhc........nonce of
U z '1'Ot'AL: ELECT RIC FEE
O the work for which this permit is issaW(Sec.3.199.Civ.CJ
Lenders Name PLUMBING FEE
u' F Lenders Address QTY. MECHANICA ERMIT FEE
U I certify that 1 have read this application and state that the above information is MECHANICAL FEE
>"' correct,lagrcemcomplywithall city send caumynNin....sared,uh,tis,relhtirgm PER TISSUANCE
I" building construction.and hereby mahorio,representatives of this city to cm,r alma the CONSTRUCTION TAX
IA(� aMwe-meminneA pm,rn,for inspcclinn partners, ALTER OR OMECH,
(We)agree to save,indemnify and keep hafmless the City of Cupertino against
Iiabilities,judgmems.costs and expenses which may in any why accmeagainst said City AIR HANDLING UNIT(TO 10,0110 CFM)
to.onsc9acna mf the granting of this Pn oun.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of ApplicunVCommdnr -Data EXHAUST HOOD(WBIUCT) PAID
I IAZARDOUS MATERIALS DISCLOSURE 1111 FING UNIT(TO 10dg0 BTUj (`Z
Date Receipt Receipt#
Will the applicant m future building racialism store or handle haaardous macrial HEATING UNIT(OVER IW,IXq RTU) TOTAL:
as defined!by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)l VENTILATION FAN(SINGLE RESID)
❑Ycs ❑No
ISSUANCE DATE
Willth.x.plicant arfuwre M1nilJingwcupam umnluipmenmrdeviceswhicheart HOILF.R-COMP(JIIP OR I(gl,f%q BTU)
.ardous air contaminants as droned by the Buy Arch Air Quality Management BOILER-COMP(OVER IW,1t0(0B'1'U)
stria?
ElYea ❑No NEW RESIDENTIAL MECH.—SQ.FL
I have read the her ard0us materials requirements under Chapter 6.95 of the JUN 15 1995
Califomid I Icalth&Safety C,Ae,Sections 25505,255]3 hnd 25534. 1 underamnd that
if the building docs not currently have it tenant h:nitlsmyresponsibi litytonotifythe CITY
,spm,of there reT ems which mixt Pd: ,o isxaanscof a cenireata if Ur k,urCH I IIUU
athmi ed, ent Dam TOTAL: ISSUF,I
OFFICE