28272 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO [%IIt I-UI NC-ELLC'I RICAL P17RMI'T NO, ^I8 L^ L
^ /�
BUILDING DIVISION APPLICATION/PERMIT PLUM N;-MECHANICAL L
BUILDING PROJECT1DHN IFICA1 RON
B•U�Ij/,/pLNG
S:
SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT
OWNIr A/i PHONE: CO ACTOR'S NAME: LIC NO �
l� /.•r !rJ ev, C/ N/C CONINDI.a
R III'TI'I'pr GINFER: O LIC NOLO AljDRESS� NEl
CON .Cj�rj' /�JV PDONE: ' S BUILDING PERMIT INFO
4 QTY. ELECTRIC PERMIT FEE
BELECT
E] /_ PLUMB MU,Cll
PERM11'ISSUANCE CQ L^vJ/
LICENSED CONTRACTOR'S DECLARATION 4APPLIANCES-RESIDENTIAL - �� 108 DESCRIPTION
OCZ I hereby affirm that l am licensed under provisbnsof Chapter9(elsommmcing with /,�^,�_ '
WOO_ Section 7000)of Division J ofthe Business and Professions Code,and my license is in PANELS ee.onPv
yW1— full force and effect.
QFLnOi Licen Li<.p S UP T02IXIAMPS
N�h Date Convector 281-100()AMPS SQ.FT,MOOR AREA+ l;/SQ.FT,
F'rnZ ARCHITECTS DECLARATION OVER I"AMPS
Z
oz-0—0 I understood my plans shall Is,usW as public records.
F=H W SIGNS ELECTRICAL
6y$� Licensed Pmfcasional
row2 OWNER-BUILDER DECLARATION SPECIAL CBNIT/MISE.
X0601 hereby affnn thin I am exempt from he Comracmr's License Law for IM1e -
W'3WmFp following reason.(Section]031.5.Business and Porm bleu Care:Any city or county TEMP.METER OR POLE INST.
which requires u permit In construct,alter,improve,demolish,or repair any svunurI
h ' nm hs l+suence,alsore heat licant formcb ,,,Men si•nod smtancnt POWER DEVICES
a poor 4uimsm PP Imcnni g
C DO ;hill he is licrosed,snonnlm the provisions ofthe Conimnnr's Licence Law(Chapter G 10T 9Penn anerring with Se'drin700(bof Division Sof the BuslnessmW Professions Code) SWIMMING POOL ELECTRIC �Y VAhUA'I'[ON
,ni, or that he is esempt therefrom and the basis far the ul leged exenmplian.Any vloladan ofOUTLETS-SW 11'C1117S-FIXTURES
FZ� Sen Pon 9131.5 by any applicant for a permit sabjeas the app]i,ant loin civil penalty of )
5ZD not more than rive hundred dollars($500). NEW RfSIDIiNT1AL ELECfR SQ.FT. STORIES 'TYPIi CONSTRUCTION
a:L ❑ I.asowncroftheprnpeny,ormyemployceswithwagesmtheirs^lecompensation,
y3°O will do the work,and the swans,is not intended or offered for sale(See.]OM,Business
and Professions Crain:The Contractor's License Law does net apply to an owner of
propeny who builds aT impmves thereon,and who does lich work himself or through his
wnemployees,pmvided that suchimpervements are not ineadedmofferW forsale.If. OCC.GROUP BFB.UNITS
however.the buildingor improvensent is will within one yearnfcompletion.the owner- TOTAL: Sy.w
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLooD ZONE APN
❑ I,as owncrofthc pmpery,am exclusively commaing with licensedconwnorsto
run the project(Sec.7044,Business and Professions,Code:)The Contractor's PFRMII'ISSUANCE n(7
I'icensc Luw Joesnnl�pplynr un owncrof propenY whnhuilJxer improves thereon.and
wM1oanyracta lin nuchProjects with aconmanor(s7licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Lice xl.uw.
❑ill nm cnempt under Scc. .❑&I'C for this reason BACK FLOW PRO'I'HC'F.DEVICEOU'I'SIDF TEES
SANI'T'ARY NssYN
(loner Dam il DRAINS-I FLOOR,ROOKAREACOND. REClPl'p
WORKMANCOMPENSATION DECLARATION . , SCHOOLTAX Y N_+_
I herchy affirm thin l have a coni ficate of Canonuoself-insure,or a certificate of FIXTURLS-PI7R TRAP ECI-IPIn
arkern'Compensation Insurance or scerlried copy thereof(See.3810,Lab C.)which 7.S`0 PARK FEE N
Il inst e's tae GAS-ISA.SYSTEM.I INC.4 OUTLETS
REM-IMNII
Policyyyy////���� ` BUILDING DIV, ON Ffi1S
Cory6any --- GAS-EA.SYSTEM"OVER 4(EA) ' 4PA1Drq"P
EE
�V CertiBW copy is hereby fumishW.
❑ Centopy is filed with rhe city inspection division. ORIISINNDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTRAP
COMPENSATION INSURANCE
(ThisscetionneeJnot becomplemd ifthepermim nforonehundreddollam(SIM) SEWER-SANITARY-STORM EA.20017.
nr less.)
I certify hat mind performance efthewnrk for which lbispennit isissued,lshall WATER I IHAT'ER WNENTIELECTR
o; c;
nploy any person in any manner so as to bmnme subject m the Workers'Dam WATIiR SYSI'IiM/1'RPATING Rc 'mlk
U Z Applicant
z0 NO'I'ICE 0 APPLICANT:If.after making this CenMeamnf l?xennuio ,You should NEWRESIDENTIALPI.Mtl SQ.FT. A1.:
p) become subject to the Worker's Compensation provisions of the Latin CWe,you must
� ? forthwith simply with inch previsions or this permit shall b,deemed revoked, BUILDFEE ��• OSS
dQ CONSTRUCTION LENDING AGENCY SEISMIC FE r. 70
1 hereby afrimnhauhere is a conswction lending,gooey Tenho perfortrmnce of
ZTOTAL: s 5—V ELECfRICFEE
U U he walk for which thio permit is issued(Sec.309].Civ.C.)
lenders Name PLUMBING FEE
u" F lenders Address � QTY. MECHANICAL PERMIT FEE
O U I certify that 1 have mad this application and sura that the above information is FE
V MECHANICAL E
>w LT7 connect. I agree to comply with all city and county ordinances and state laws saluting to PERMIT ISSUANCE
F"' building conoraction,and hereby iuffil represenumivesofthis city m enter upon the CONSTRUCTION TAX
U Z abovearicalonW property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupcninn against
liubi..re'. lgnunla.co>ts and expenses which may in any woy accrue againet sail Ciy AIR HANDLING UNIT P70 10,100CFM)
it quo of the grumin 10Tsp
n AIR HANUhING I1NIT(OVI?R I(I,INq CPM)
rcof Appll,arn C^moor ! ate EXIIAUSTHOOD(WIDUCT) 7•S�
PAID
u HAZARDOUS MATERIALS DISCLOSURE HEATING ONE"T(TO 100,00)BTU) Date FReelipt N r
Will the applicant m home building occupant sore or handle hazadous material HEATING UNIT(OVER 100.00 BTU) 1'01'AL oS
as defined by the Cupertino Municipal Code,Chapter 9.12,and be Hcalth and Safety
Code,Section255320)° VENTILATION FAN(SINGLE RESID) Jill 28
Cl Y. Na
ISSUANCE DAT
Will the applicant or homebuildingcecupant use equipmmmnmrdevittswhichemit BOILER-COMP(JIIPOR 100.880 BTU) CITY
OI'
sourvi air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) V LUI"'C�I I INU
Diet a'1
❑Ycs o NEW RLSIDENTIAI.MECH. SQ.lef.
I have read the havurJous materials requirements under Chapter 6.95 of the
Colllimmia Ilcahh&Safety Code,Sections 25505,25533 and 25534. 1 understand that —sem
if;he milling Jo,s nntcurtendy use a tenant,that i;is try resp;msihiliy to notify the 0c pu t of the rcyuiremems icb moss be r n-mance o Cer' Tote of -
Dc ap0,01
umM1orirsd agent Dam TOTAL: 39-S 0 ISSU1iD BYU Oe-
OFFICE