28222 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
iS� CITY OF CUPERTINO
BUM=: MARACA L PERMITNO 22^^
8
\ APPLICATION/PERMIT PLUMBING-MECHANICAL L L L L
U BUII,IIING DIVISION - BUILDING PROJECT WENT IFICATION
FITINGA DRESB: (///�(�.`�/, SANITARY NO. APPIICKDONSUBM/UTALL DATE
40MACT:
\\1 0��� �— `' _— �� UNIT# LOTH
ERS H' PHONE: CO I1 1 jJIME LIC NOya, N/C CONTROL# l J
N OOl
I IITECT/ENGINEER: LIC NO: DRESS:PHONE:
QTY. IiLECrRIC PERMIT FEE BUILDING PERMITPLf5B PO
1. G ELECT PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 100 DESCRIPTION
Z=Z I hereby affirm that l um licenced under prvvisionsofChaper9(commencing with
�00 SeNon 7(h)(HaDiarsims 3 ofbhe Business and Profession,Code,and my license is in PANELS
y V fall force and effe 68 7 7S 1116"s-%
CZ[�❑i�1 License Clncx Lic.p y UP TO 200 AMPS �nVt3
y<y ale Ournmo for 201-RISE AMPS +r
Fye ARCHITECTS DECLARATION SQ.14.FLOOR AREA SISQ.FT.
O
Z m E OVER HXp AMPS
OZ� I understand my plans shall used es puhlie rereads.
(=mC SIGNS ELECTRICAL
� $ Licensed Pafesxionil
1� OWNER-BUILDER OFLARATION SPECIAL CIRCUM'/M15C.
OaF 1 hereby n.(Scffirm dim 1 am exempt f the omrnLicense Law for the m following reason.(Section 703 LS,Bmin an([11 essiones Code:Any city or county TEMP.ML'I'ER OR I'OLIi(NST.
which requires u permit to constmet,n q improve, emalish,or repair any slructum
Pty"Ij prior to its issuunce,also¢quire,fle plicantforme pc tmitmfle.,i,redshomeart POWER DEVICES
y)K¢p that he is hemsal pursoanunthe visionsoffleO butlers License Law(Chapter
4 0�' 9(commencing with Section )of Division3ofthe usiness and Professions Code) SWIMMING POOL E'LECT'RIC VALUATION
•_y or that he is exempt here and the hasis for aIle d exemption.Any violation of OUTLETS-SWI'I'CIIES-FIXTURES
F$ZQ, Section 7031.5 It applicanlforapermitsubjeeb, vpplicmam.civilpenallyof
N 0 net more the a hundred dollars($500). ; NEW RESIDENTIALELECIR. S FT.
p� ❑ I,as tens lhepngcrty,armyemj�lnyeerwithwag sluebsolecnmpensdier, Q STORIES TYPO CONSTRUCTION
y will dos work.vnd the slmcuuisnafppppppyye,,.n,�d��eA uraffertd Tortola(Sec.]0G4.Rusirlese
and P tromps Ede:The Cnnbhe u knee Law oes not apply to an owner of
Protein vEmbuildsi ndwhodm ichworkhimsehorthroughhis
own Iuyecs,pmvident .emenD nolimenJedorofferedforsnle.If, OCC.GROUP RFS.UNITS
howeve,III build'gar irnpr �m nussoldwl toonoyourofcnmplmingohonwner-
builder ill have tl bit i en,^to that h did not build or improve for pm mm of TOTAL:
s I`)' TY. PLUMBING PERMIT FEE' FLOODZONE AJU
❑ I,n.owvenufl pro- nyiumcaclu vely contracting will,llcenud ro:nmcmts to Q
cnnswn he pn:jmi ec 7l ,Bus' est and Professions Code)The Comrvam's PERMIT ISSUANCE
License l.:wdocs not upplym vn own ofpropeny who builds orimproves lhereon,anA
whoconbm¢forsuchprojeclswo commcmr(e)licensed punuanuo the Contractor's ALTER (EA)
License La IEE SUM1`
❑ I um c empt under See. II&P C lot this reason BACK FLOW PRO'I'EM.DEVICE O ID .Ell t
SANITARY Y N
Owner Date RECEII'1'p
44
DRAINS-FLUOR,ROOF,AREA,COND.
WOR AN COMPI?NSATION DECLARATION SCHOOL TAX YN
❑ Iherthye trout bl have viceni0cvu of conunuo ulf-insum,mattnificate of FIXTURES
covers
TRAP RECEIPT#
Wnrkeos'Crm Mn tmn Insurance or a citified copy thereof(Sec.38W,Lab C.)which PARK FEE Y N
all employee's under this permit. GAS-FA.SV59LM-I 1 OU'ILF.TS RECHIPP#
Put icy p _ BUILDING DIVISION IHS
Company GAS-EA.SY TEM-Oli EA) PLANCHECK FEE
❑ Certified copy is hereby furnished. is
❑ Cenifed copy is flet with the city inspedinn division. GRIT SEAND R ASTEI O GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAE SOILS FET:
COMPENSATION NSURANCE
(This semionneednob be compleled ifthe permit is for one hundred dollan(E1 W) St - AI`T Y,/STORM ?A.200F1'. ENERGY FEE
or less)
Icomfy that in the perfomusame of the work for which this permit is is a ca I A'-R IIEATb ENT/EI.ECTR
not employ any person in any manner art a to become subject to the WorkersPAID
Z Cnmpen,miov Lxwsof Cvllfomiu. Date WA SYSTENVTREATING Dam R eipb#
Applin nt
zC) NOTICE TO APPLICANT.If.after making this Cenifceu of Exemption,you should NEW RESIDE- IAL PLMB. SQ.PT. TOTAL:
Le) become subject o the Workery Compensation provisions of the Labor Code,you must
> forthwith comply with such previsions or Permit hall be,deemed revoked. BUILDING I>'
GCONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ I hereby affirm that hen is a construction lending agency for the performance of TOTAL: ELECTRIC FEEO llm work for which this purmil is issued(Sec.309'1,Civ.CJ
Lenders Name
Q F I.ender's Arlene,., QTY. MECHANICAL PERMIT FEE
PLUMBING FEC
V I certify that I hint real this application it sone Ihm the above information is
7" correct. I ague Rs comply withill city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEH
building conmructiogaM hereby mart imupuseamlivex ofthis caym enter upon the CONSTRUCTION TAX
fJ Z above-havon purryrses. AL TER OR ADD 10 MSCI I.
(Wead keep harmless the City of Cupertino against
l iuhililicn, cs which may in ony way accrue ugaitnl xuid City AIR HANDLING UNIT(TO 10,00)CFM)
in< nuqpermit.
.J AIR HANDLWG UNIT(OVER 10,000 CFM)
gnamaL Dam EX14AUST 11001)(WNUCT)
PAID
HAMA'TERIAIS DISCLOSURE HEAFINGUNI'T(TO100,000BIU) Date Receip#
Will theapplievat or future building occupant store or handle hazardous material HEATING UMT(OVER IW,OW BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Iladlh mid Safely
Cade,Seem.2553201? VENTILATION FAN(SINGLE:RFMID)
Cl Yes ❑No
tISSUANCE DATE
Will theapplicamorfumm huildingoccupanbuseeyuipmemordevicu whichemit BOIIPR-COMI'(JHPOR IOII,INq 6'TU) W p e
huwdaus air eoremenams av defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) �'1 ® s
istricIT
❑Ycs ❑No NEW RESIDENTIAL MECH.—SQ,FT. /t V •/
1 have mad she rely Coe,materials requirements under 34. fur 6.95 of thethat
C7�Y 1995
California Health&Sufdy Code,Sections 25505,255)3 and 25534. l understand mat �//-
if the building docs not currently have a para.that it is my responsibi lily to notify the LI/h'rh
occupant of the requirements which mush M ma prior to issuance of a Certificate ofi{I Ihpl��'
Otwpuncy. jjj�Y/Y/Y/...AAAsssIVVV111wp///N/`/`/55`'
Owner or umhnrized agent Date TOTAL: ISSUED BY: U
0FFICE