24843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBIL I LKU MICALPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL _ A Q /I O
BUILDING PROJECT IDEN'PIFICAUON : 4 u 4 J
BUILDING ADDRESS: /�,I I^/{—�- 1/� SANITARY NO. APPLICATION
-SUBMITTAL DATE.
dotiiaiI 11760 44oLj / 9I Ve UNIT# LOT is ��!'�N">
OWNERS ypME: ^�� )' 10 PHONE:_7q� CON'PRAC'I'OR'S NAME: LIC NO: N/C CONMOOL# ♦♦l/
\RC/IVT�'zF;CTG^`/6f NN NEER VR V f I A �n4LTC NO n ADDRESS: ❑ ^2
CONTACT': PHONE:i `J
N^r�L• /yrs/s �/^Q ELECTRIC PER FEE
r cBUILDING PERMITINPO
W it 4CIS BLDG EL PLUMB MEGH
PERMIT ISSUANCE. S .(�n t[�]jL.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-REI G 1 �QV JOB DESCRIPTION
ppgZ I hereby xffimvhat l am licensed underprovisions of Chapter9(commencing with it'
POR Section 7")of Division 3 ofthe Business and Professions Code,said my license is In P /
U� full forceless effect. -
4 License Class Lia# ® pVO P A
6 Vi Dole Con[melnr 20 1 0 PS
2Oy� ARCHITECT S DECLARATION I AMP QI ORA $/S .
FZ n G I understand any plans shall be used as public recoMs.
y�; SIGN ALECTRIC V IS
G��d Licensed Professional ' ��r
EU pe< OWN ER casupt AIDBC,Chirac ON SPECIAL.CIRCUIT/MI 7 VY'
0,x OyF 1 hereby affirm that 1 um exempt from Ne Conions Co License Law amino (_Q
YFl.'3�y¢ watch follolrequir s a parn(Setion V031 5, t,after.improve,
Professions Code:Any city sari y TEMP.METER O INS IV
1W,Y, V{77VJ�S
p a,O..I wbicM1 requires a pemmil nm construct,alter,improve,demolisM1,or repair any snucwrc
CA�'}� prionoits issuance,also rcyuires the applicant for such pemiitln fleasigned stsamm, :POWER Vl S
W O that he is licensed pursuant to the provisions ofihe Contractor's License Law(Chapter
a' a 9(wmmuaing with Sectlan)000)of Divislon3 of the Business and Pmfessions Coda) SWIMMIN L C VALUA Glp
ly,_y onhmheivexempt therefrom and the basis for the alleged exemption.Any violation of
a Seniun 9031.Sby any applicant forapenbiteubjems the applicovnuucivil penalty of ELF—
GO
-PIXTURBS
not mom than foe hundred dollars($500).
Po ❑- Lasowneroftheproperty,armyemployeeswi,h wagesastheirxoleaimpensation, NEW RESIDENTIAL ELECTR _SQ,FT, c�—npRIEIA TYPECONSTRUCHON
will(to work,and the structure is not intended or offered for sale(Sec.9044,Business a
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimproves thereon,andwhodoessuchwork himselfor throughhis
employeee,providedthat such improvementsarenotimutdedomfFarad forevla If, l 1 CC,fR RES.UNITS
however,the building orimprovemeat,sold within one year ofeempletlon,the owner- TOT L: l� '(✓ 11l
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,avownerofthe property,amexcluslvely contracting with licensed contmctomto QTVx. - - -PLUMBING PERMIT + APN
construct the project(Sec.70FI,Business and Professions Code:)The Contracture c -
LicenseLowdocsnotapply man ownerofprnpertywho builds orimproves therech,and PERMIT ISSUANCE
who contracts for such projects with acnatimetor(s)licensed puruantto the Contractors ALTER EA
License Law. ( ) 3v0� - FEESUMMARY -
❑ I am exempt under Sec. ,B&P C for this reason PACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dara DRAINS-FLOOR,ROOF,AREA COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm that have acenifcmc of consenuo self-ia ons"eacenifen'at' pIXTURES-PF.R TRAP / O� RF.CF:IPf#
IN hers lnsumnceoracenified wpy thereof(Sao.J800,Lnb CJ whleM1 9 6- PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS --I1 RECEIF
Pot icy it ?r UO BUILDI DTVI NFEE
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECKFEF O
❑ Cxnifiederd, sherebyfunumbed.
CenifieJ copy is fled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FF' n�
CERTIFICATE Of:EXEMPTION MOM WORKERS' GREASETRAP SOILS O ,ter
COMPENSATION INSURANCE,
or les(His section need not be completed iflue permit is for one hundred dodam IS IBd) SEWER-SANITARY-STORM EA.200ET. ENERGY FEE
I certify that in the performance ofthe work for which this pemrit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkerPAID �fl
Oz ACPPpcan^tmion Lawsnf Culifomie. Date / WATER SYSTEM[]SEATING 00 Dam
r
C NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should N EW RESIDENTIAL PLMB. f.SQ,FTOTAL:
rA become subject to the Worker's Compensation previsions
ons of the Labor Code,you most
both.im comply with eueli provision,or permit shall be deemed revoked. BUILDING FES
L1a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE T
z I hereby affirm promote is a remodelled lending agency firths,performance of ww l.J
U Q the work for which this permit is issued(See.3099,Civ.CJ y
TOTAL: � ELECTRIC FEE
1
ry Lenders Name IPLUMBING FEE
0 U Lenders Address - QTY•. MECHANICAL PERt °� - r FEE"
o*O
U I certify that I have and this application and state oat the above information " "1, `
w
correct.ler agree to cora with all cit and ordinances and state lows relating to PERMIT ISSUANCE= Q MECHANICAL FBI.
a n comply yon yo g ' `�
UIn buildingconstructioninryand herebspecti nprepresentatives of this cirymen,er upon the q CONSTRUCTION TAX
U above-mentioned progeny,for inspection and purposes. ALTER OR ADD TO MECIi. q',Op
(We)ogrpe rt save,indemnify and keep harmines the City of Cupertino against
in
of hcast,ande
ex penseswhich ands in any way necrueagxinst said City AIR HANDLING UNIT(TO 10,000 CFM)
consequence of the grarying of this permit.
V) b'2illilk
\neo 0 AIR HANDLING UNIT(OVER 10,000 CFM)
—QIiitiIIiIIIIIi64
Signatumof Applrardt"a actor Date EXHAUST HOOD(W/DUC'I) 6�SV
PAID
HAZARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO 11X1,000 BTU) Dote Receipt#
Will the applicant or future building execution,store or huadle hazardous material
as def red by the Cupertino Municipal Code,Chapter 9.12,and,he Health and Safety HEATING UNIT'(OVER 100,000 BTU) TOTAL: I
Cissa Section 32(x)1
❑1 ye, 0N VENTILATION FAN(SINGLE RESID)
Willthea licaat orfumre huildin fusee BOILER-COMP(3HPOR100,000BTU) ISSUANCE.DATE
pp gocenpnn qulpmenmrdcioes whlchomh
emNous air contaminants as defineRR-
d by the Bay Area Air Quality Management BOILECOMP(OVER]bit II BTU)
)19VIC19 P A'1 1)
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.FT.
I base read the hazardous materials requirements under Chapter 6.95 of the O
California Heath&Safety Code Sections 25505,25533 and 25534.1 undoraaed the, �
if the building done not currently have a tenon,,that it is my responsibility,o notify the A
occupant of the"idusmeas which most be met prior m issuance of a Cenifeme of
Occupancy.
fiiIt V V L(TIIIVf� \
Owner or authorized
In, Data TOTAL: Q. ISSUEDBY:
OFFICE