24561 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO f ILD;N(:-MA.CTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBINI:-MECHANICAL /1 ^4 J l6 C/1�
BUILDING DIVISION BUILDINGPROJEC1'IDEN'IL'IFICAIION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'IH
O�/ ✓,w NE• G� UNRN LOT#
r O ' GMF P O F:: CONTRACTOR'S NAME: LIC NO:
kky 7t —Q NIC CONIROLN
\R011I CT/ENG EER: LI NO: IAI=ESS: ❑
CO.YTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BhDG EF :5 MECH
PERMIT ISSUANCE
LICENSED CONTRACTORIS DECLARATION APPLIANCES-RESIDIi JI AL JOB DESCRIPTION
Qmz I hereby affirm that l am licensed underprovislons of Chapter9(commencing with
WOO Section 70004o1'Division 3 of the Business and Professions Cole,and my license is in PANELS
s W full force and effect.
6jW LicenseClass Li..laUPT02W AMPS
H<� Date Contractor 201.1000 AMPS
Fy% ARCIII TECTS DECLARATIONSQ.FT.FLOOR AREA $/SQ.FT.
LO0 y 0 1 understand my plans shall he used m public records. OVER IINNI AMPS r
t:,yFW SIGNS ELECTRICAL i� L E D 'sed orn �e
Q j LicenPrufessil r 1 V
ttyd'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ����
OW, I haffirm that athat 1 am exempt from the Crearectar's License Law for the P
W'3 t' following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.M171 ER OR POLE INS
�°< which requires a permit to contact,alter,improve,demolish,or repair any structure D TE �a i �J/
YSprior to itsissuance,alsomqulre.+the applicant for such Permit to file a signed statement POWER DEVICES
Et C Q that he is licensed pursuannn the provisions of the Contractor's License Law(Chapter
dSo 9(commencing with Section Division 3 of the Business and Professions Cade) SWIMMING POOL ELECIItIC VALUATION J
W❑y no he,he is emmpt Nerefiso andthe basis for the alleged exemption.Any violation of
,4< Sec1lon7031.5 by any rundicum for a permit subject the applicant to a civil penalty of OLD LM S-SWITCHES-FIXTURES
fl.thatwe"
rchanfivchundn JJollars,m00). STORIES '1'YpECONSTRUCTION
NF.W RESIDENTIAL ELI!CIR _SQ.I•I'.L' pmowneroftIhe pen"aano,mpinyce.+witM1wagsasthcirsnlecnmPenatinn,
and The stmcfurtisnotimenedmoffered Torsale(Sce.9d44BusinessoionsCadeThe Contractors LittnxLawocsnotapplyfesanowerofhobuilds mimproves thereon,and whodoes such workhim¢Ife tbmughhisaf "ces,provided thmauch impoeveriumsurennt intendedondfered tarsale.IL OCC.GROUP RPS.UNITS
however,the building or improvement is sold within one year ofcompletion,th4 owner- .pff.
bui her will have the burden of proving that he did not build or impmve for purpose of
salcJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las owneraf the prvpeny,amexclusively contacting with licensed contactors fes
unstmct the Project(sec.701 Business and purification,code:)The Comment's
Licenx lywdocs not applYn an ownerofpropcny whobuildsmimprovesthcreon.mJ PERMIT ISSUANCE
who contract for such projects with a contractor(s)licensed pursuant o the Contractor's Al:MR-DRAIN&VIzNT-WATER(EA) FEE SUMMARY
License Law.
❑ I am ceempt under Sec. ,B&P C for this reasonBACK PLOW PROTECT.DEVICE OI]:.SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm that l have a certificate ofmment to self-insure.or a certificate of FIXTURES-PER TRAPRECEIPfp
Worked Compensation Insurance or a certified copy thrroogsce.3800,Lab C.)which - PARK lY N
,oversell employee's under this profit. GAS-PA.SYSTEM.I INC.4 OUTLETS RECEIPT N
BUILDING DIVISION FEESPolicy N
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certified copy is haehy famished.
❑ Certified copy is filed with the city inspection division. GREASEnNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICAI H OF EXEMPTION FROM WORKERSGREASE'I RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed iffhe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.2001`. ENERGY FEE
or less.)
I terrify that in the performance of the work for which this permit is issued,lshalf WATER HEATER W/VEP'I'RiLECIR
nor employ any Person in any manner as to become subject to the Workers' PAID
Compensation haws of Cvlilirmin. Dale so WATER SYSTEM/IREATING Date Receipt It
O Z Applicant NEW RESIDENTIAL PhMB.-SQ FT TOTAL:
z NOTICE TO APPLICANT:If.after making this Cenificae of Exemption,you should
r y become subject to the Workers Compensation provisions ofrhe Labor Code,you must
> forthwith comply with such previsions or this permit shellm
be dcccd revoked. BUILDING FEE
4LI F CONSTRUCTION LENDING AGENCY SEISMIC FEE
2I herehy mftirm that there's a resurrection len lu g.gers,fur the performnce of TOTAL
a
U O The work for which this permit is issued(See 3099.Co.C.) : ELGCI'RIC FEE .�
Ixnders Name PLUMBING FEE
OF Ixnders Address QTY. MECHANICAL PERMIT FEE
U I cer ifY tum I have read this applicnion end smb,that rhe above information is MECHANICAL FEE
>" correct.lagree to comply with all city and county ordinances and state lewseclatingm PERMIT'ISSUANCE
F' boildiagcoretuchimmJhe..hyamh repr mtivesafthischyto cntcrupomhe CONSTRUCTION TAX
U Z ubovcmcmumod Frupeny fmins rp ALTER OR ADD TO MECIL
(We)agree to s y ke arnlcs the Cit f Cup, inn ag not,
liabilities,' nt rivosaan ape sw may in yacemeag 'Tsai City AIR HANDLING UNIT LTO 10.000 CFM)
in co the grand AIR HANDLING UNIT(OVER IB.01)CFM)
ne/o 6 9
Signaturcot Ai)pliC' / rllnranr distate EXIADS'I'HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(10 100,000 BTU) Date ReceiptN
Will the applicant or future building oacupont store or handle hetrulaus material HEATING UNIT(OVER 100.000 BTU) TOTAL:
afin
s deed by the Cupertino Municipal Cale,Chapter 9.12,middle Ihealth and Safety
Cade,Sectio 25532ho? VENTILATION FAN(SINGLE RESID) '�-
❑Yes ❑No
ISSUANCE DA M
Will thea licarter fuwrebmidin cupantuserympmen tordeviceswhich emit BOILER-COMP(3HPOR IWW
.OBTU)
pp d b
hvsNnua air comin
nfaanb as defined by the Nay Area Air Quality Management BOILER-COMP(OVER IW,tXIp BTU) If�k
District? ❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.ff. r A 1 D
1 have read The hmurdom,materials rCyuimmems under Chapter 6,95 of the R
Califon.Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that IWn Y s
But.building does not currently have a anent,the,it is my responsibility to nmify bus,
occupant of the requirementsat which must be mprior to issuance of o Certificate of
Occupancy. Cu ,r 'L _ i
Owner or:mthori cd agent Date TOTAL: ISSUED BY:
OFFICE