28077 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,TTY OF CUPERTINOH ILDI ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 28077
BUILDING DIVISION BUILIIINGPROJECI'IHEN'I1'IIFICA' ON
BUILDII�NGAADDRFSS: SANITARY NO. APPLICATIONNSSUBBMITTAL DATE
o/C? UNITk LOI'p � — /-}—�
O ERSNAME: PHONE CONT CfOR'S NAME: LIC NO:
o�V
2
I5 - 1 OS WC CON'I'ROLN
AKCHITECCI;NGINEER: LIC NO: A DRESS: < ❑
I)59 u.(
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
52-3q 3Z BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ r?1p ED
LICENSED COSTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
np ZZ Ihusbyafirm that l an licensed under provisions ofChaocr 9(commencing with
�00 Section ought)(if Division 3 oflhe Business and Professions Code,and my license is in PANELS r//5
,Z, Limll me anderinn.
6FZ� License Class Lic.p UP T0200AMPS
rn Q=y I)mc Commcmr 301-1(100AMPS SQ.FT.MOOR AREA EISA.Un
ZOyZARCHITECT"S DECLARATION OVIiR 10(1)AMPS
07_0 I understand my plans shall be,used as public remands.
F y L:ea SIGNS ELECTRICAL
�Y_V' Liccnscd Professional
e(WQ OWN17R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XI hereby affimIham
t foul 1 exempt from the CoLicense Law chas License for 0e
lu3n-vFi following rcuum.(Section 003 L5.Business and Professions Code:Any city or county TIiMP.MEf1iR OR POLE INST.
I'u'0¢ which squires a .it If,construct,alter,improve,demolish,or repair any nmucmre
prior to it,Issuumce al......ses IM1e spplicamfo...eh permiun file a signed atammcm POWER DEVICES
cef <c that he is licensed panuan to the provisions of the Contractor s License Law(Chapter
EL se y SWIMMING POOL ELECIRIC
(rontmencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATION
m=m or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
F-zQ Section 7031.5 by any applicant for a pcmtit.subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
SFO nal more than five hundred dollws($50o). NEW REMDINTIAL ELECfR_SQ.Pf. STORIES 'TYPE CONti1AUCTION
M p ❑ I.nowneroflhepmny,ormyemploynswlthwagesastheirsolecompensalion.
pc
a3c= will clothe work,and the structure isnot intended moffned forxale(Sm.70x1.Business
and Professions Code:The Commenor s Liceme Law does not apply loan owner of
propcny who bulld.sorimpmvcs th.ram,and whodoessuch work himself onhrough his
employns,pmvidecl that such impmvemenlaumnol inlendedorafferN f.rsale.ll; OCC.CROUP RES.UNIFS
hwwevm.the building or improvement is sold within one year of completion,the ownef-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
'`ale')' QTY. PLUMBING PERMI•I' FEE FLOOD ZONE APN
❑ I,asthe project(Sea
7Da, exclusively professioingns
s Ccxie n)Thesed contractors to
mrtarun IM1e project ISec.1044,Business and Ro(cssions Code:?The C.mmclor'x
10 License Law dues not apply mamownerofproperty who buildvor improves lhereonand PERMIT ISSUANCE
who contracts for such projects with aconlmclor(.$)licensed pursuant to the Contractors, EA AI:I ER-DRAIN&VENT-WATER
License Law. (EA) PEE SUMMARY
❑ I am exempt under Sec. .B&P C!or this reason BACK FLOW PROTECT.UEVICE O 1'SIDE FE 1 g
SANITARY YN
Owner Dam RECEIPT N
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMI'ENSATconmatCLARATIre SCIIOOLTAX Y N
❑
Workers'
pfBlmin,laxiveaeertifcatemle.,thew.Gin,ure.or a ce C.)which
FIXTURES-1'I7R TRAP O O RBCEII'I'p
Workers'employee,Compensation, mail. ificdcopY,hereof(Stt.3800,Lab C.)which PARK FEE Y N
n sllemployee's under This pennil. GAS-EA SYSTEM-I INCA OUTLETS RECEIPT p
PolicyPolicy# BUILDING DIVISION t7:FS
Company GAS-EA.SYSTEM-OVIeR 4(EA) PLANCHCCK FEE
❑ Cmircdcopyisheubyfumishcd.
❑ Cenificd copy is filed wilM1 the city inspection division GRFASEJINDUSTRL WASTE INTERCEPTOR GRADINGFE-C
CERTIFICATE OF IiXEMPTION FROM WORKERSGREASETRAP SOILS FEC
COMPENSATION INSURANCE
(Thiss'cetion need nnlbccompincd iflhepcnnit fsfocone hundrtidollari($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or tax,.)
I mamlylbut firms,performance ofthe work far whichthi,pernil is issued,10.11 WA'1'ERIIHA'1'ERW/VC Ifl.EMR
nut employ my person in any manner so as to become,subject to the Workers' PAID
Compensationlawsof Califomfa. Dam WATER SYSIEM(IRFA LNG' Dam Reeefple
Z 'Z Applicant
O NO I ICE TO APPLICANT':IL after making'his Cenificae or Exemption.yoa'lumid NEW RESIDFN'I'IAL PUSH. SQ.FI'. TOTAL;
Z,J^ became subject,.the Worker's Compensation provisions of the labor Code,you muss
F_
a > forthwith comply with such provisions or this permit shall h deemed revoked. BUILDING FEH
W Q CONSTRUCT ION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for The mlimance of
U O TOTAL r ELECTRIC FEE
the work for which this pcit is issued(See.1091.Civ.CJ
F.cndsev Name PLUMBING FEF.
u'' F Leader,Address QTY. MECHANICAL PERMIT PER
V I certify that 1 have read this application and state that the above information is MECHANICAL FEE
coral.l agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE
buildingconstruction,and hereby inire muntatives.f,his city to entero the
Yau P tY pan CONSTRUCTION TAX
(J � aMwe- cmioncd property for fnspenion purpose,. ALTER OR ADD TO MECII.
(We)agree,m save,indemnify and keep omits,the City of Cupcnino against
liabilities.judgments,cnsls wda which may,.any way Timing,against said City AIR HANDLING UNI'1'Q'010,000 CPM)
jn onseq; rd I gmnlin pc il.
AIR HANDLING UNIT(OVER 10,00)CFM)
Si sure of Applicont/Conmcmr Date EXHAUST HOOD(WIDUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt N
Width.applicant or rumre building occupant smreor handle Inuadoux material HEATING UND(OVER Hsi B I'U) TOTAL:
as definal by the Cupertino Municipal Code,Chapter 9.12,and the Hcallh and Safety
Code.Saliun 25532(.)? VENTILATION FAN(SINGLE RESIU)
❑Yes ❑No
IS U N DATE
Wilhheapplicam nr fmmebulldingacuponl usceyulpment ordeviees which emit BOILER-COMP(311P OR IIXI,IXIII IfT'U)
dour air conmminann as defined by the Bay Arca Air Quality Managm
eent BOILER-COMP(OVER 100,000 BTU)
°""?
❑Yes ❑No NEW RESIUIiNT1A1.MECH.—SQ.FT. JUN 28 1995
I have read the hmard.us materials reyuircments under Chapter 6.95 of the
California 11calth&Safety Code.Sections 25505.25533 and 25534. 1 understand that LFII Vr VUi I INU
if the building drres out currently have a tenant.that it is my rexponsfbilily to notify the
occupant of the re9uirc nsaux which must M met prior to issuance of a Certificate of
Ownerormuthadoed agar Date TOTAL: ISS EDB
OFFICE