28045 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IDiISINC-EEISCTilt PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 8 O
BUILDING PROJECT UIENI'IF'ICA'1'ION
45
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMITTAL DATE
L GV {{/Rti GNI'1'# IAT#
OWNERS NAME: PHONE, CONTRA DR'S NAME: LICNO:a zG NN/C COfROLp
RCHITECDEN eER: LIC NO: ADDRESS: ❑ "
'OFH'ACf: PRONE: BUILDING PERMIT INFO
Q'I'Y. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB - MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT'IAL
Ih...h ffinnthmlam licenuJ under fChe t 9(cormnencin LOB DESCRIPTION
O tYZ Yo pmvicionso per gwith
�00 ho"
Section
em"I of Divisian3of the Business and Professions Code,end myliunu is in PANELS I�(� _
ed full forcesendeffect. ` ,/6�:,�Jr.(r�.L�+
License Clan Lic.a - UP TO 200 AMPS L it,<y Data Contractor 201-I"AMPS
20y'� ARCHITEC'T'S IDECLARATION OVER IOIXIAMPS
f:. c.iq SQ.FT.FLOOR AREA $/SQ.I'1'.
O Z_ I understand my plans shoal be used as public records.
rn 2 SIGNS ELECTRICAL
Licensed Pmfessinral
_Wx< OWNER-BUILDER DECLARATION SPECIAL CIRCUODMISC.
P�OyU I hereby nfRmr that I um camnpt from the Contractor's License Law far the
9130 fall.wing mrsob(Seen..7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�� which requires a permit.emotmct,alem,impmam"emolish,or repair any smmuce
Prior,,it,lasmoon,slsn requims the upplicaot rorsuch permit o file a signed smemem POW M- DEVICES
EIY<o that he is licensed pursuant m vectors the Provisions of the ConLicense Law(Chapter
a o 9(ricamormeing with Section 7")of Division 3 of the Business and Professions Cattle) SWIMMING POOL ELECTRIC
VALUATION
\ _y or that he is exempt therefrom and the basis forthe alleged exemption Anytemationnf
t �• Section"1117 LS by any vpplic:mt fora OUTLETS.SWITCHES-FIXTURES
t �Z< permit subjects the applicant macivi�penalty of
Q t�more than fva hundrcA Dollars(E500).
C q $ I,asowncrnfthe n NEW RPSIDENIAL ELGCfR S .F1'.
e Gi111 propctomis not ntle
compensation, Q STORIES 9'YI'P.CONSTRUCTION
a3o0 rnhewons and the he Contractor's
License Law red
not apply
anti Professions Code:The Commctor's License Lnw Joes not apply to an owner of
pmpeny whobuilds mimproves thereon,and whodaea ouch work himselfordarmi hhis
on cmployees,previded that such improvernatim snot imandmomffved forsale.If, OCC.GROUP RIS.UNITS
however,the bulldingor improvement is said within one year of completion,theowner- TOTAL:
builder will have the burden ofpmving that he did not build or improve for puryose of
t).
❑
reasoner
.,act
(Smlu 041,1, exdusi, it
Clicensed conwmor In
QTY. PLUMBING PERMIT PEE IL.00D'LONE APN
conumn the project(Sec.]Oa4,Bus ss end RuPossions Code:)The Convanm'e
License Lavishes not apply to an ownerofpropeny wbobm1d,r=Pmvesffio=.ond PERMIT ISSUANCE
whnenmransfmrsuch projects with acontractor(s)licensed pormanuothe Commetnr'a pI:fCR-DRAIN&VENT-WAT13R
Lima a law. EiA) FEE SUMMARY
❑ I am el ander B&P C for this reason h EFF..
BACK PLOW PROTECT'.DEVICE 01 SANITARY YN_
Owner Dat DRAINS-FLOOR,ROOF,AREA,COND. RECHIPT#
KMAN COMPENSATION DECLARATI SCHOOLTAX Y N_
r❑ Iherchy of rat thatlhuveettnificete of cmnscnno self-insure,orecenificete of FIXTURES-PER'1RAP RFCI:IPI'Y
Workets'Compensation Insurance or a modified copy thereof(Sm.3891,Lab C.)which PARK ME Y_N_
covers all nnployce's under this permit GAS-EA.SYST'IiM-I INCA 0lfI'LGJS RF.CHIPT e
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenified copy is film with the city inspection division, GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE?
CERTIFICATE OP EXEMPT ION FROM WORKERS' GREASE TRAP SOILS Fl3E
COMPENSATION INSURANCE
(Th....ion readmit hecomplded ifthe permit is Room hundred dollars($100) SEWER-SANITARY-ST'ORM HA.2001q. ENERGY
or less.)
I certify that in the peH'otmance of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/EL[CfR �
nm mop),any pcm.a in any manner so as to become object to the Worker' P
CnmPensationaswsof Califnmis. Dote WA TER SYSTEMITREATING Dme cip
0 Z Applicant _
Z � NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENT AL PLMIL SQ.Por 'AI:
t•' VI b«onm subjecno the Wnrkda Compensation provisions of the labor Code,you must Eli T
a ? forthwith comply with such pmvisions or this permit shall he deemed revoked. MCONSIRUC
Ct1 � CONSTRUCTION LENDING AGENCY -
Z I hereby affint that there is a construction lending agency for the performance of
U 0 the work for which this pnman is issued(Sec.3097,Civ.C.) )
I<adcr's Name
Q F Lender's Address QTY, MECHANICAL PERMIT FEE
L) I canify that 1 have mad this application and stem that the above information is
coned.l agree w comply with all city and county ontinances and state laws riming to PERMIT ISSUANCE
building consraction,and hereby minimize representatives of this city to enter upon the 54
U above-mentioned pmpcny for inspection purposes. AIAERORADDTOMF"CIL X
(We)agree m sive,indemnify vad keep harmless the City of Cupertino against
liabilities,judgments,emission expenses which may irony wayaccom against said City Alit I IAN IDLING UNIT(TO 10,000 CFM)
in cents atimnce of the gmating of this permit.
AIR HANDLING UNIT(OVER 10,(%10 CFM)
Signature of ApplicarmCommctor Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('I'D 100,910 BTU) Date Receipt to
Will the afflicted or future building occupant store or handle hazardous material
as dcdined by the Cupepino Municipal Cale,Chapter 9.12,and the I IcahM1 and Safely HFATING UNIT(OVER 100,000131U) TOTAL:
Cate$Callon 25572(s)T
EI Yes kNo VENTILATION FAN(SING,LE RPSID)
SSU' NJ1}�JATE
Will theapplicamorfumre building occupant use cquipmem or devices which emit BOILER-COMP(31 OR 191,00)BTU) 4 U
�M1amnine, it canmmioanw ns defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1011,910 BTU) ��� A
District?T
❑Yes No NEW RESIDENTIAL MECH. SQ.FT. �f/y 41 a� 'An�
I have read the hazardous materials requirements under Chapter 11.95 of the /a/ 1. �7J
Calif.a a H &safety C ,Sections 25505,25533 and 25534. I understand that
if rhe build' g anmcun e aIranian,nam,that it is my responsi hi lity to notify the
rccupnnt o t quimmqVglcch hprior to issuance"is Certificate of V
Occupy
Owner or ambo' agetho
Data TOTAL: ISSUED BY:
OFTIM