24573 fl
LICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O I I'Y� �D 7
Y OF CUPERTINO R n. - LE11a1 AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24573
331LDING DIVISION "BUILDItNGPROJR(H'IDENTIFICATION-INGADDRESS: gANll'ARY NO. APR.ICATIONSUBMITTAL DATE
/f // UNIT# LOT# rR M PII NE: CO R CTO 'S NAME: LIC NO: N/C CONTROL#❑.CT/E GINEER: LIC NO: ADDR /V ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT - FEE-
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RF,SIDENTIAL JOB DESCRIPTION
OWzPOO Thereby affirm that.amliconeedunss iredsioions oPC Code
(co mmencing is in
�00 fail Section of Divielen3 of the Buslnase end Professions Code,and mylicense is in PANELS
m run roma dna arc
<� ucens n Llc.# UPT0200AMPS
is, a Dale 5 — commanr (/p�/y.
1"nOiN ARCHITECTS DECLARA'T'ION --"� Z01-IDOOAMPS S IT.FLOOR AREA $/SQ.FT.
O z_l= OVER HIM AMPS Q'
O Z^'O I undermond my plans shall be urea as public roc*1 IO
rr J SIGNS ELECTRICAL
Lmensed Protosetonol
CC OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O W F hereby mss n (Serom tthat
ion 1 am exempt from the Conlractods License Law for the
W3Wm following mason(Section
AGI.S.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
soOa which requires a permit to coasnum,almq improve,demoliah,orrepain any Soul
am�Q� prior In its issuanognlao requires tneappllerm for suchpomlO.file a,ignitd statement POWER DEVICES
G�Oa that no is licensed par suunuo the provisions of the Contenders license Law(Chapter
0.o 9(commencing with Section 9000)ef Division 3 of the Bisinessund Profesalons Cede) SWIMMING POOL ELECTRIC VALUATION
iW_m antro heisexm nt by
rltfromsaathe baspermitonhenllsged ltxemant to civil
of OUTLETS-SWITCHES- I,� /Y T ® 1� �
Section7031,5than
by anydledapplicant dollforapermit suM1jeds Iha applicant toacivil penalty of FlXTURGS II r \ \V� `
G
not more than Eve hundred dollars($SW).
n�' ❑ Lmownerofiheproperty,ormyemployeeswith wagesas lheirsolecnmpensation, NF.W RESIDENTIAL GLGCTR _S >P. -1 / D STG ' y� 'TYPE CONSTRUCTION
m _ will dotnework,andthestructure isnet intended orofreredbeside(See.7044,palamus,
an J i B ,p,.[`
and Professions Code:The Contractor's License Imes does not apply to owner of
property whobuilds arimproves lhereonand whodoessuch work narration lhroughhis
own employecs,proviaed that such improvememsare Dot tmendederoffema forsnle.if, UP RBS.UNITS
however,the building orimpmverecal is sold within one yearofcompletiory thcowner- TAL:
builder will have the burden of proving that he did nal build or Improve for purpose of
sale). . _
❑ I,as owner ofthe properly,am exclusively contracting with licensed contractors to QTY' PLUMBING PERMIT 'P "FEES ; FLOOD ZONE ANN
wnstmet the project(See.3044,Business it Professions Cedc:)The Contractors
License Law delta not apply toanownerofproperly who builds dr impress,dresser,and PERMIT ISSUANCE
whoconlraats for such projects with acomraetar(s)licensed pursuant to the Contractors
License Use. At,I HR-DRAIN&VENT-WATER(EA) - FEE SUMMARY
❑ I am exempt under Seo. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUT IDE FEES
Owner O SANITARY YN
Dote DRAINS-PLOOR,ROOF,AREA,GOND. RBCBII"P#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ Ins Co penrm thmlhave aemiifieate nifie cup,thereff(Sce.38,er Lab C.)aile ofwhich FIXTURES-PER'IRAP RECEIPT#
Wdrkem'Compy7s siipsd denaeoracertified copy.hereof(Sec.3800,Lab C.)which PARK FEE Y N_
,hero allelepIeyp de tri ��I., .� GAS-HA.SYSTEM-I INC.4 OUTLETS
Ul/,Z_ZU Y-YJ- RECEIPT#
Policy# BUILDING DIVISION FEES
Company�'9py is '� T
OAS-ffik.SYSTEMOVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby Famished.
;�<Cenified copy,is flea with Ne city inspection division. GRFASE/INDUSTRL WASTE.INTERCEPTOR
GRADING 4EF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ME
COMPENSATION INSURANCE
(This section inertial be completed iftnepennit is handle handled dollars(SIM) SEWER-SANITARY-STORM EA 200FT.
or less.) ENERGY FEE
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENryELECfR
not employ any person in any manner so as to become subject to the Workers PAID
Z Compensation Lawsof California. Date WATER SYSTEMITREAT.NG pale Receipt#
C, Applicant.0 NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESI DENTIAI,PLMIL SQ,IT. - TOTAL:
pTA become subject the Worker's Compensation previsions of the Labor Cole,you must
f rc hwitit comply whit such provisions or this permit shall be deemed revoked. BUILDING FEE
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
p z I hereby affirm that there Is a construction loading agency for the performance of
V O the work far which this pemtil is illead(See.309,Civ.C.) TOTAL: ELECTRIC FEE
LLi r- Leaders eqm
O t<nao Address QTY. MECHANICAL PERMIT ", FEET PLUMBING FEE
c I certify that I have read this application and state that the above Information is _
a earect. .agree¢,comply with all squad army ardderressand state lave,oduing to PERMIT ISSUANCE MECHANICAL ME
q] building cooffiucteamand herebyinfoeve representnlivesofthi,city to cuterupon the
U K above-mentioned propeny for inspection purposes. ALTERORADDTOMECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acuneagalnsl said City AIR HANDLING DISH'P(TD 10,000 CFM)
in consequence of the grafting of this permit,
AIR DANDLING UNIT(OVER 10,000 CPM)
Simulate of ApplicentiConnactor - Y Date EXHAUST GOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('TO I00,000 BTU)) Dam Receipt#
Will the applicant or future building de.Cam store or handle hazardous materiel
us dennee by the 32m)?no Municipal Code.Chapter 9.12,and the Health end Safety IIEA'TING UNIT(OVER 100,000 BTU) I T(1
Cada Section 255]2(x)9
11 Yes 11 No VENTILATION PAN(SINGLE RESID)
Will the applieam er futurebuilding occupantuse equipment ordevices which emit
BOILER-COMP(THP OR bg000 BTU) ISSUANCE DATE
r tmMous air commnlnunts es dolled by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
isaia9
❑Yes
' o NEW RESIDENTIAL MECH. SQ. F. PAID
1 have rhe&S hm cars mat els require to under aides 6.95 of the DEC 2 1993
California thblbuilding
do&Sof y ode,5 s 5505, 533.d2 34. 1 undltmtena thai
t' thebuilofthtloesnn cntly alenu h of ii is my re once
aymfifica the
\\I upunt of the re u' ems usl I prior to is u e C inoam of -
tl iiscupancy.' r .C�IY Uf �ur't 111`
rain ,it gent Dare TOTAL: ISSUED BY:
OFFICE