28434 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI HICAL PERMITNO
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 Q A O A
BUILDING PROJECT'IDENGFICATION v'•F J�•F
BUILDING ADDRESS: 1 {w� SANITARY NO. APPLICA'OON SUBMITTAL DATE
1
•fq ` IWC LOT# s
OCZ,NA � PII li:/� CONTRACfOR'g NAME: LIC NO.
\J�' a N/C CONTROL#
ARC]111'13CLIiNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PRONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT(NPO
BLDG ELECT PLUM NVII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION PPIAANCES-RESIDENTIAL TOB DESCRIPTION
LOQ
Matz Ihere00.1' mthoo 3ofth Business
irofesions Code,and
with � �i�
001 E fall oufour ad effect.Division the Business anti Professions Cak,wd myliccnu is in PANELS T+
,<Zw License
Class effect.
FZ44]] License Class Lic.# UP 90200 AMPS
m7yData Contractor 201-IOW AMPS
ZSHE ARCBITECTS DECLARATION (WER TWO AMPS SQ.FT.FLOOR AREA 5/SQ.PI'.
bZ—� and my ens ell Rus des uId nods.
r L: un SIGNS ELECTRICAL.
Q g�� Licensee mfounal
�i OWNER-BUILDER DEC RATION SPECIAL CIRCUUUMISC.
6X,�aF I hereby affirm that 1 in exempt form the Convector's License Law for the
u13LLtn followirkJoewnn(Simeden)1131.5,Bminteiand Prnfussier,Cod¢Any cityor county TEMP.METER OR POLE.(NST.
F uJ or which requires a permit to construct,alter,improve,demolish,of repair any Sonoma
Kn�' prior to its issuance,also requites the eppfcam for such permiuo file esignM smmment POWER DEVICES
,,< that he is licensed pursuanuo the previsions ivim Contmcmr's License Law(Chance
a q.oL' 9(commencing with Section V000)of Division 3ofthe Business anti Professions Code) SWIMMING P001.ELECTRIC VALUATION
iW❑N arms,he is cacmpdrumfrmn and the basis forthcalleged exentptinn.Any violation of -
h-.ya
Section]031.5 by any applicumfor a permit subjects the applicnnnr u ci,pemtltyof %40; OUT'LET'S-SWITC]IES-FIXTURE
S /
O not marc than five hundred dollars(55W).
tY��p ❑ Lasnwnemfthepropmy.mmyemployeeswithwagesumeirsolecomperemiun, NEWRISIDENTIALELECfR _SQ.FT. STORIIS TYPECONSTRUCI'ION
y3— will do the work,and the swcmre kn timeaded proffered frrsale(Ser.70il Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work hintselfor through his
wnployces,provldwltbatwchimprovemcntswrenodntendeJnrnffcredforsolc.lf, OCO CROUP RES.UNI'T'S
however,the lmilding orimpmvcmem is Reit within one yearofcnn¢plminn,the owner- /+
builder will have the burden of proving that M1e JiJ not buil)nr improve for purpose of
'de')' QTY. PLUMBING PERMIT FEE FLOO
❑ I,asownerof Ne prnpegy;ein'e�c`Rtylvrvly onvaning with licensedcontraaorx to D ZOE "Nconstruct the project(Sec. M ,Business ana'Pblf, inions Caee:)The Contractor's
Licenscl.awdoesnotuppIYlo Etnomerofpropertywhrbudd¢pnitPprovevhereon,nnJ PERMIT ISSUANCE
who...ammo,mrsuch prNecis with a crytQ(()de)licensed pursuant BthsComractnr's
License Law. !L •wt., ALT13R-DRAIN&VINT-WATER(13A) FEESUMMARY
❑ 1 am<ncmpt under Sec. Bi&P C for this reason. +,. BACrK Iq.OW PNO'IECI'.DEVICE ID[ 4
Owner T - .'p(m SANITARY Y N
• DRAINS,00R,ROOF,AREA,CONU. RECEIIT#
WORKMANCO S 'LgN DP,C4ARATIO SCIIOOLTAX YN
❑ Ihorehyuflorrim lh ve a cwh ood"of con£etis to self-Inlurf. ria certificate o1 FD7URI�L PER TRAP RECRIP`F#
Workerti Compcnsalirnln en there. (Sec,.1�0 LabCJ hkb t PARK FEE YN
rs aIle pgnde un permit Q � GAS-RAISYSTEM-1 INC.4 OUTLETS RECEIPT#
Polley# n •�� �l BUILDING DIVISION FEES
Company '" ' GAS-E A.SYSTEMOVER4(EA) PLANCHECK PER
(7-CutifcA copy is hcrabyf m(iN'Fd. �¢�
❑ Ce"at copyiaftlea with the city ntxpeei nN isoa RI3ASIrJINDUSTRL WASTE INTERCI3PfOR
��`,p��¢ GRADING FEE
CERTIFICATIi OF EXEMPTION FROM WORKERS' r
,; i- GR 4 SETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the Permit isfor onehundred dollars(SIaO)r vy .u5$4I3R-SANITARY-STORM EA.20KPf. ENERGY HE
of less.)
Ivanil'y 0mt in the peifnr nowenfthework for which this pawardis issued,Lvbal l WATER I1EATER W/VENT/ELECTR
not employ any person in any mourner so as to become subject to the Workers' PAID
Z Compensation Lowso(Celifomia. Dam WATER SYSTF.M/IREAT'ING Dam Receipt
Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Ccnificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.UL OTAL.
r VI become subject to the Workerm
Worker's Compensation provisions of the LuhurCede, m
youust
R� forthwith amtply withsuch powmans or thkeernthxball bedeemwl revoked. BUILDINGFEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FE
V z I herebyaffimtthattherection mitemarulendingagenm
cywatheperfmanceof
O the work for which this permit is owned(Sec.3007.Civ.C.) TO FILE FEE
V CK
Lender's Name P
w0 F Lender's Address QTY. MECIIANICAL PERMIT' PEE
PLU G :
U I certify that 1 have.,],his application and some that the above information is
correct.Ingrcmocomply with all city anti coumy ordinances anti¢tate laws reletingm PERMIT ISSUANCE M13CIIANICAL 1I3E
�"' building comwnion,and heathy authorise rcpmsenmtives of Nis citytoemer upomhe
V Z above mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCIONTA
(We).9.will indemnify and keep harmless the City of Cupertiao against
liabilities,judgmeme,costse Icxpcnses which may in any way accrue against said City AIR If ANGLING UNIT(TO 10,000 CFM)
•oI fi mm yrf/ltisacrmit.
(/o-`/I AIR HANDLING UNIT(OVER 10.000 CPM)
ignamrcu Applicant mrector Dane EXNAU9I'110OD(W/DUCT) 1
PAID
HAZARDOUS MATERIA 'DISCLOSURE HEATING UNIT(TO 1110.000 BTU) Date Receipt#
Will licapplicatn or future building occupant smrc or handle hazardous returned HEA'T'ING UNIT OVER Il10,W0 BTU
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I Ieabb a (OVER Safety ) TOTAL:
Code,Section 25532(aT!
E)Yes ❑No VENTILATION FAN(SINGLE RESID)
re
Will the uconta tiaras di.defireg by the Bay Am
Quality
BOII.ER-COMP(3BPOR I00,OOOBTU) 1$S CE A '.
hazaNnus air contaminants as defined by the Day Arca Air Quality Management BOILER-COMP OVER IW,000BTU) JUL 11
Diso-ictY 1995
❑Yes ❑No NEW RESIDENTIAL M13C11. SQ,FT.
1 have real the hazardous materials 5505,25533 under Chapter understand
of the CITY ser "UrEHIINO�
California Ing lchdo&Safety Cute,Sections rm,that
25533 ane,pomil 1 undersmne that O
if reapsa ilding does rumen which must hot,ohm rior my rsuanceibila Certificate
the
occupam rl the rcqulremoms which attar be mm prior m issuance of n Certificam ref
Occupancy.
Owner or awM1odud agem Data TAL: ISSUED BY:
OFFICE — — I