24687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELMA RICA I PERM(I'NO.
,S
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MRCHNICAI. 24687 q
BUILDING PROJF.C'IADh:N'I'IFICAIION 4
,UILDIN I SANITARY NO. APPLICATION SUBMITTAL DATE C �� A I Ica& UNITN LO I'#
OWNF SS'T � CONTRA�1'OR'S NAB /� ,I.IC NO i N/C CO��
ItCI{IT' T/HNGINRER: LIC NO ' ADDRESS rV"JN/V ❑
J
CON'I'ACC PHONE
r QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
HI.DG ELECT PLUMB MHCII
1 PERMIT ISSUANCE ' �� ❑ %SA ❑
LICENSED CONTRACTQR'S DECLARATION gppLfANCF.$-HF.SIDENTIAI.
I hercb Ilan thallam bxen+cJ under (Chu l 9lrmm�mncm 1M1 JOB DESCRIPTION
OC'Z Y^ prov i+mnsn per gwI
PA00 Section 900f).f Drvhann 31fthe Buanessimd Prnfessmre Code,and my license is in PANELS N�
FC W EF. full force and effect 11
6VU Lmenx Clms Lic.# 1 UPT02MAMPS
on y hate Coattail— 201-I0(m AMPS
7ON{ ARCHITECTS DECLARATION SQ PF.FLUOR AREA E/SQ PI'
OZ.- I understand my plm+,ball IN,used as Public records OVER IWIIAMPS
F-•E�Icl Locator!Pnvessi.nal SIGNS 171.I?LT RICA[.
u OWNER-BUR.OFR DECLARATION SPECIAL CIRCUIT/A11SC.
KOe 1 hereby affirm that 1 am exempt from the Committees License Law for the 70 1
wPoo following reason.(Section2031.5;Bnanessand Professmns Code:Any Oymermarty l TEMP MITER OR POLEINST.
I901 whar acquire,a permit In conslmU,alter,improve,demolish,or repair any so eture
{2j2 pnrrmitsiwuanc'e,eRO rcymre+theaPplreum for sucM1 permiuofilea,ignedefatement (POWER DEVICES
W K QC)s that he is licensed pm+aanl m the provisions of the Contractor's License Law(Chapter
LixL 9(commenemg with Section 7W)of Division 3 ofthe Business and Prefesaons Code) (SWIMMING POOL Ir.1.GCfRIC y VALUATION
W_rn or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
�zQ Seciion70315 by any apphrnnt for a PCmnt subjects the applicant ma civil Penalty of OUTLETS-SWITCI IHS-FIXTURES
re IN live hundrcJ dollar,(ES(p).Wm rn . ( NEWRESIDENTALELECIR —SQ STORIES 1'YP?CONSTRUCTION
L Ill dothe wart,soil fM1e xtiuclureiwnnntendmlora ffered for s:de(Sec IB44,Bmines+
nd Profe,xium Code"I M1c Contractor's haemc Low doer ram apply n,an owner of
prnpeny whahuildsorimpmvee iherenn,wJ whndoessuch w.rkhunxlforthrough tin
own employees,p building or improvmentisvld witinne y1hooedoplebon ownef, OUP RFS UNITS
however,vidltbuilding origin rp emwmldwnhmo[build ormaperveon,theoaw,rr fir
sue.). will hoax the harden of pnrvmg that he did not build or improve far purpn+c of
Clio).
❑ I,mownerofthe property,mnexclmrvely contracting with lrcenxdcnnwnuvtu QTY. PLUMBING PERMIT FEE I FLOOD ZONE APN
I!msvucr the protect(Sec.7W.Business and Professions Code)Ile Contractor's
innse Lawdne+nmapplym anowne,ofPmpeny whobuddsor improves their.,and I PHRMff ISSUANCE
License Law.tin such protects withnconvamor(,)I¢enxJ pursuennothe Cunvaanrs ALTER-DRAIN&VENT-WATER(EA)
License taw. FEE SUMMARY
❑ 1 um exempt under Sec. B At P C fear this«moo BACK FLOW PRO'1'IiCT DEVICE I SANITARY OUT'IDF FEES N
Owner Dale RECEIPT# _
WORKMAN COMPENSATION DECLARATION URAINS-ROOR,ROOF,AREA,COND SCHOOLTAX YN
o❑ I hereby affirm that l have a certificate ofconsent to self-inure,orucemfi 4' of VIXTURES-PERTRAP RPCF.IP # __
r1cdCmin,oxmtnn lnsnrunce orn cemfed copy fhercnflSec.3g00.l.rah C.)wbch (PARK THE Y N
covers all employee's under this permit GAS-li RIiCIi1Pf#__ ___ _-_-
A SYSTEM.]INC 4 I T,
Policy If s �C BUILDING DIVISION II?GS
Cnmpam - GAS-EA.SYSTEM-OVER 4
❑ CertifcA copy is bitchy fumisheA. PLANCIIECK FEE I
❑ CertiOcJ copy I,fi1cJ wnM1the ivy mspecuon drum., GREASEJINDUST'RL WASTE IN'FERCEPIOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP SOILS FEE
COMPENSATION INSURANCE
(This section neeAnnt he conpleteJdthe permit is for one hundred dollars($1� try E �N I j�Y�ST M p
ENERGY PEE
or less)
L scruffy that the perormanae ofthe work for whmhthts N ur:,sissued,lsh I t ry
not employ any person In any manner so as to become subject ni the Work •2 I� EpR�WjpI PAID
Z Compensminnlaws of California D:^ ,d 5YS9�.MRIt IV,PING Dole
Recetptq
Applicant
O 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should DAI PEW A SQ IA TOTAL:
� bcurm,'abJort to the Worker's Compensation provisions of the Labor Code,you must - - _ A
Ki 7 tearthwth comply with such pray lions or this pennn shnl l he deemed revoked•- BU I LIIING FEE
CONSTRUCTION LENDING AGENCY SEISMIC ICES
Irk hereby lbc,h isQ,mI,,,,mnsvucr.3lendingagency for the performance of TOTAL F,LECI'RICFEE
U O the work Ina which thl+permit n n,ucl lSec.309],Cit.C.) - �
Londel,Ni I PLUMBING FIiIi
C F^ I<ndcrsAry It. (QTY. MECIIANICAL PERMIT FEE
U certify fun I have martins city and cou and mate that the above information cid hnn a
burred construction,craidy and with all lutenti nnaesnramancof ant state)enerupnthe PIiRh11'I'ISSUANCIi MECIIANICAI.PI?E
builJmgcon,tru<tion.nnJ hereby authentic representatives of this cnymenter upon the CONST'RUCf10N TAX
U above- nod pmpcdy for lnspccuoa"=%less ALTERORADDTOMECL
e)rag •e m save,indemnify and keep harmless The Cny of Cupemno against
Ilahllme,, it nen0,costs andexpense+U&P gai nst said Cny AIR HANDLING UNI'1'fIO III,1N10 CFM)
efile•ranting oftha pe y_
/�'I/IZ AIRIIANDIANG ONIT(OVER Ig000 CFM)
ri ( Dole EXIAUSTIOOD( /D1CTgnmure of Applmam/Conirntim ( PAID
HAZARDOUS MA'IT?RIAIS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Data Nscript
WAR the applicant or(more bulldog occupant score or handle M1arurdOn,motion HEATING UNIT(OVER 100,000 ItTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.11,anti the health and Satoty _
Code.Section 25532dy? VENTILATION FAN(SINGLE NISID)
❑Y.- ❑No
BOILER-COMP131IPOR IW,(NId BTU) ISSUANCE DATE
s will air co ic.nf cums as defined by pant u+ Area Air Quality Ma agement P A I D
dour tar c.ntemmrnD as defined by the Bay Area Air Qualify Management TOILER-COMP(OVER 100,(NNI BTU)
?ntncC
❑Yes ❑No NEW RCSIDEN I AL MECH SQ.FT
- - I have read the for ard.a,oriental,rex mremena under Chapter 6.95 of the JAN 20 1993
California Oca1m&Safety Coda Seeman,25505,25533 and 25534. I undersmad that
rf tho bmldmg does not currently haver tenant,that n,x my responsibility m notify the
rcapant of the requirements which meat be met prior m Issuance of a Cerlmcale of CITY OF GUrr M1 D
Occupancy
Ow net tor...hortaMagent Dale I TOTAL( IISSUED RY:"Xcwf
OFFICE