28260 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUII.DINO-ELEC'I'RLCAL PERMITNO. L^^ ^�h/^O
APPLICATION/PERMIT PLUMBING-MECHANICAL VX L
BUILDING DIVISION BUILDING,PROJECT IDENFIFICAT'[ON
,RU
,]T.pING ADDRESS: SANITARY NO. APPLICA///TI��IOONSNUBM.ITTALDATE
O ERSNAA IH PI30NG: �3Y03 CO RACfOR'SNAME: LIC NO: N/C CONTROL II
Irl ' me k 631-7 Er
• ARCBITECTIENGINEER: LIC NO: AUDRVS "Ado kA I El
CONTACT: PHONE: 1' 1
QTY. EL17CFRIC PERMIT IBUILDING PERMIT INFO
TE
BLDG ELECT PLUM. MECH
PERMIT ISSUANCE? ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm that on licensed underpmvidonsidChm
apter9(comencingwith
WOO Section 7")o(Division 3 of the Business and Professions Cade,and my license is in PANELS /) _
yFF�F full freeundeff Is ]T�\.-J`
6'yU License Clusy 'aV
Contrah,"3 . 44 �..f^.-- UP TO 200 AMPS
yQy De¢'1'flY- - "AA 201-Ip(p AMI'$
ZOrN in ARCHITECTS DECLARATION OVER IWO AMPS SQ.Fr.FLOOR AREA S
OZ,- lad plws shall be used ae public records.
=7
SIGNS ELECTRICAL.
gi� Licensed Professional
� OWNER-exempt ironDECLARATION SPECIALCIRCUIT/MISC,
Dxx'OaU 1 hereby affirm that 1 am exempt from the Contravenes License law for the
followW 3 O n which tag mmnn.(Sectionito 7031.5,commuct,Business and Profusions h.or re repair
city or county TEMP.METER OR PULE INST.
which requires a pcmdt to constmn,alcor,improve,demolish.or mprsir rsny swemm
� Y� prion.its issuance,alsome,irea theapplicent fim.mh permium filers signal domain POWER DEVICES
.,-<2 that he is licensed pursuant m of the provisions the Conuactors License Law(Chapter
a n,o9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
XID�m or that he is exempt therefrom and the husis for the alleged exemption.Any violation.( OUTLEfS-SWITCI IIiS-FI%TURLS
F G Section 7031.5 by any applicant for o permit subjects the applicant o civil Penalty of
1 more than five hundred dollars($500). . '.
M
m❑ I, sownerofthepmLady,.rmyemployceswithwugesasthnx
eirsolecomlxmiNEW RfSIUCN3'IAL CLECfR
on, SQ RISTORII?S TYPE CONSTRUCI ION
d will Jo thework,and thestructure is nor i ntendedoroffeeed for sale(Sec.]044,Business
and Professions Code The Contrncha'a License Law does not apply to an owner.f
property whobuildsorimprmostureon,and whodoessuchwork hlmselforthreughhir OCC.GROUP RFS.UNITS
ownemptoyces,provided that such improvements utenot intendedoroffered formic.If,
however,it,building orimprovement issold within one year ofcompletim,the owner- AL,
builder will have the burden of Leaving that he did not build m improve for purpose ofjel
ale.).
El I,asownerofthe MWny,amexclusivelycontractingwlN]ice.edcontractorst. QTY. PLUMBING PERMIT FEB FLOOUZONE APN
corm uct the project(Sec.7014,Business and Professions Code:)The Contmcmr's
License law does noupply loon ownerofpropeny who buildsorimproves thereon,and
PERMIT ISSl1ANCF? �s
who contracts inrsuch projects with a contrumor(s)licensed pursuanu.the Contractor's
License Low. ALTER-DRAIN ffi VI',NT-WAT.R(EA) ITE SUMMARY
❑ lain exempt under Sec ,B&P C for this maann ,I E FEES
BACK FLOW PROTIiCI'.DEVICE OU SANITARY YN
Owner DateSCHOOL TAX Y RF.CEIPTY
N
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARE ,GOND
❑ Ihercby amr
fdthat lhave aceniBcme mammal nuno Ulf-insure, certificate,oracerticertificatecvof ' C -URES.PERTMPn ,4 •r RECEIPrp
Workcrz Compensation Insurance oacenifeJcopy there PARK FEE Y
Nyf
coven all empoye.1's Uthi ytlt.,*O`, a GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDINGD VISION FEES
Policyp �a NT`1`1 `k
CnJnpwY
Ji,
H ' r — - STI? 4(FA) PLANCHECK FEE
® CerideAcopylsherebyarnished.
❑ CeniOed copy is 0lrA wiOnhe city inapcnion di vision. ^ G - FB D 9TRL TE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKE'aC/ G F. AI SOILS FEE
COMPENSATION INSURANCE
(This xectinn need nm he c.mplemA it the permit is Toro hu�dmlQQllgrair) A RY-STORM 'A.200PT. ENERGY FEE
or less.) i LJ/1 I C
I cenifythnt in the performance ofthe work for w3ich Ni tisiomed.Ishall WATER HEATER W/VEIYrX (CTR
not employ any Person in any manner so as to brume subject to the Workers' PAID
z Compensation LievemCalifomia. Data _ L WATFJt SYSTEM/IEFFTI'ING.. - Dam h iptg
Applicant NEW RESIDENTIAL PLMB. SQ,FT.
Q 0 No come su j APPLICANT':Worker's
ork IL after Composedness
this C idoses of of La ser Cod,youou must J OTAL:
F-' In become subject m the Worker s vismpevmion provision of N¢labra revoked,
must
Ki 7 fnnhwith comply with such provisions or this pcmtit shell be domed rtvokW. BUILDING HE
W z CONSTRUCTION LENDING AGENCY SEISMICFEP
1 hereby affirm that there is a construction lending agency for the performance of
L) O the work for which this permit is issued(Sec.301 Civ.C.) EI,F. E
Lender's Name
�F lender's AddressQTY. MECHANICAL,PERMIT IBC; PL. BI FEe
V I certify that I have read this application and state that the above information is
Fcorrect I agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE Ir ^ MEC C FEE
U) building convection,and hereby a donse representatives ofthis city incineration the
V Z above-mentioned property for inspection purposes. ALTERORADDTOMECII. CONSTRUCfION'f
We)agree to save,indemnify and keep h remeu the City of Cupertino against
Imbilitim,judgments,costs and expenses which may in any way sccrue against mid City AIR HANDLING UNIT(T010,000 CFM)
inconsequence. the tmntng of this Persil
/` /G AIR HANDLING UNIT LOVER 10.000 CFM)
Signatu'reof ApplicunVComtmct r Dam T EXHAUST HOOD IWP)UCI9
PAID
HAZARDOUS MATIiRIALS DISCLOSURE HEATING UNIT(TO 100.0M)BTU) Dam Rc ei
Will the applicant or future building occupant store or handle hazardous material NGTING UNIT(OVER 1!1(1,00(1 BTU)
as defined by the Cupertino Municipal Coote,Chapter 9.12,and the Health and Safety
Cale.Sermon 25532(a)'I
11 Yes ❑No TIVENLATION FAN(SINGLE!BESIDE
BOILER-COMPUIIP OR 100,000 BTU) ISSUANCE E
Will the applicants.,future refiring by he
Bay Arcus Air Qualitc Management
• hasuNnus yr nmmminants az de0nal by the Buy Arca Air Quality Management
Official? 00 BOILER-COMP(OVER 100,0BTU) W •�11 Yes CINo NEW RESIDENTIAL.MECIi. SQ.FT.
1 have read the hamrdous materials requirements under Chapter 6.95 of the JUL
JVf
1um �9ars`cY
Califomia llenllh&Safety Code,Scmions 25505,25533 and 25534. dcrstandthut �P �Nh
tithe haddingdoes not currently have if tenant that it is my responsibility to notify the (f L
occupant of the requirements which must Ix met prior m issuance of u Certificate of r..ur`,1/ -
Marione,
Owner or rumored agent Date T ISSUED
OFFICE