28212 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.RiTuTRICAL PERMIT]r No.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION RVILDIRU PROJECT IVEN'I'IFIOATION 28212
BUILDING ADDRESS: }�(7 SANITARY NO. APPTUICATIONSUBMIITTTALDATL
LUNIT'p LOT /_^% -LJ
OWNEN.'NAMI?: PIIONE: CONTRACTOR'S NAME: LIC NO: N/C VVV CONTROLY 1r
15� ung -g d7
aIRCHIT1iC171iNGINIiP LIU NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INF'G
p1.OG IiLEl El ❑l P MP
PERMIT ISSUANCE FIs-dAs
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIMION
pytz I hereby affirm that l am licensed under provfsionsofChapunt)bommewing with
Pa00 Section 7")of Division 3 ofthe Business and Professorial Cash,and my license is in PANELSfull
Fq<ZFyI force aa effect.
License ClasLiaM UP102WAMN Vk'-
"VF,
mF.Qy Date Contractor 201-IOIID AMPS
ZOv`d'i7.] ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA VSQ.FT.
0z—g:% 1 understand my plans shall he used r s public swords.
r 4 L SIGNS ELECTRICAL
4 p� MU l
Licensed ProfessionaOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.xyx],O tl L) I hereby affirm that 1 am eaempt form the Cotndual License law for the
W3a oo following meann,(Section 703 L5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INST.
Ebo'I which re'mic,a pernat m construct,alte,improve.demolish,or repair any structure
K t°yL>-� prio mit,issuunee,nlmrcquires the applicvm for such permit to Elea signed ammment POWER DEVICES
WK<O that he is licensed pursuant to the providmocifthe Comracme.License Low(Chapter
la'aor 9commencin SWIMMING POOL ELECTRIC
( gwithSmion 7tlW)of Division 3nfthe Business and ProkuimnsCale) VALUATION
W❑y or fart he is excmpuherefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant a a civil penalty of OUTLETS-SWITCI IFS-FIXTURES
9G
not marc than Eve hundred dollars IS500). NEWRESIDENT1AL-ELECIA —SQ,FT.
❑ I.asdo The
wrk,an tawsepmny,orsomeone
I ms(Sec.704a,B linen, STORIES TYPE CONSTRUCHON
d3� will dathewons cord; he Com anot e mended or Law
do s not apply t oan owner ss
of
and property
who
cord;The Commandoes
,License law deer not apply to an owner of
prop,rtywhubuildsorimpravesthhoprovaJwbodraensuctende conformmselforal
Throuforsaghhia f. OCC.GROUP RES.UNITS
own employees,pingurithatsuchimpmvrld witsserenetintendedmplelin,lbeo . r-
huweveethebuildingsurImprovemesnissoldediinot year ofcompvc,fio,mmoveeof TOTAL:
builder will have the burden of proving that he did not build or improve for purrysse of
ale.).
❑ husmwner(ifthe prapeny,are exdusivelycomracting withlicensed comradorsro QI'Y. PLUMBING PERMIT PEE FLOOD ZONE APN
construct the project(Sec.7054,Business and Professions Cale:)Tim Contractor's PERMIT ISSUANCE
License Law does not apply to an owner of ptpcny nwho builds or improves thereon,add
whocontmmts fmsnch projects withacorImcteds)licensed pursuant to the Contractor's
License law. ALTER (VA)) FEE SUMMARY
❑ 1 ata exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O DF. PES
SANITARY Y N_
Owner Dam DRAINS-FLOOR,ROOF,AREA,CONE. RECIiIPTN
WORKMAN COMPENSA'T'ION DECLARATION SCHOOL TAX Y N
❑ Ihcrtby affirm thetlhaveaudificam ofconum to self-insure,oratxnificam of RECEIPTIT
Worl,c 'Compmtsetion insurance or ucettified copy thercof(Sec,3gW,Lab C.)which TEXTURES-PIiR TRAP PARK IEE Y N
covers all employee's under this permit RECEIPT p GAS-M.SYSTEM-]INCA OUTLETS Policy p BUILDING DIVISION FEES
Com
El Certified h
copy is ereby,famished, GAS-LA.SYSTEM-OVEN 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INfCRCEPTOR GRADING FEE
CERTIFICATE OF IiXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectum need units,emmplefed iftor permit is Farm,hundred dollars(S10f0 SEWERISAN A)Y-STORM EA.2t EPT. ENERGY FEE
or Ido.)
I certify that in the Performance ofthe work for which this permit is issued,l shall WA { ER W/VLNT/T;LE
not employ any person in any m as to become subject to the Workers' PAID
Compensationlawaef Celifomia. Date so TER YSTEMITRRA NG Dna Re PP
Z NOTICE TO APPLICANT:IL uftermekingthis Cedificete of F.aemption,you sho WRISIDENfI SQ.FT. OTAL:
(~ IA become subject o the Worker's Compensation provisions ofth,labor Code,you mu
f nthwith comply with such provisions or this permit shall he dttmed revokW. BUILDING FEE
�•
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FE
V z I hercbffi
yarm that hem isoconstruction lending agency funs,performance of - 'TOTAL ELF: iC
0 the work for which this permit is issued(See 3097,Civ,CJ
D. Lender's Name PLUM
Leaders Address QTY. MECHANICAL PERMIT FEE.
WL certify that 1 have read Nis application and state that the information infomtion is MECH .ANIC FF.
correct.l agree to comply with all city and county ordinances and state Inwa relating to PPRMITISSUANCE
building conutruaion,and herthy malonce representatives of this city to enter upon the CONSTRUCTIO AX
atonal,Wunsolicited e property for inspection Purposes.herr ALTER OR ADD TO MECFI.
U H (W¢)agree ru save,indemnify and keep M1armless the City nl Cupertino a ng City,
liebilities,judgmema,costswdexpcnus which may in anyyyy �st s� Cory AIR HANDLING UNIT(TO IO,000 CFM)
inin-aseque u ngofthispermit. 6 _
AIN HANDLING UNIT(OVER 10,000 CPM)
Signature of ApplismosContractor m EXHAUST HOOD(W/DUCT) PAID
IIA RDOUS MATERIA DISCLOSURE I EATING Ubfr(To I W.oW B'TU) Dam wcipt0
Will the applicant or future building mccupaat store or handle hamrdous material
as defined hymn,Cupertino Municipal Code,Chapter 9.12,had the Head h not Safety HEATING UNIT(OVER I N),Ofgl ROD '1 TAL:
Codm,Swti 0Yes ❑No 25532(a
❑ )7
VENTILATION PAN(SINGLE RESID)
BOILER.COMP(3HP OR I00,N)p BTU) ��� ISSUANC ATE
Will tThir c...nomads as building by tilentuse Arco Air ualityceswhichemit /tt
matrict? air comuminums as defined by the Bay Arco Air Quality Muneyeme0l ROILER-COMP(OVER 100,00(1 BTU) Ale �aa
District? � VV
❑end
❑No NEW RESIDENTIAL MECH. SQ.IT.
I have read the fallSafety
Coe,materials 5505,25 etas under Chapter understand
of the
ifthe buil Healthy Safcty CWe,Sections25505,t it
andresponsibility35534. lunderstand that
if the building doesam custet w have a tenant,that it is my uace to dread the
Occupant of the rcquiremems which must be met prior to issuance of a Cmifmate of
a,apaa,y, i
Owner or awhonsed agent Dam TOTAL: ISSUED BY:
OFFICE