24801APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPEPLUMBING-M MECHANICAL
BUILDING DIVISIONSION APPLICATION/PERMIT
IBUILDINGPNOJE(; 1' IDENI'IFICA770N
PERMIT NO. 24801
'a ^ H O i
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4
BUILDING ADDRESS:r
2lV eo W"KSUS �/� a�
ITP LOTp
SANITARY NO
A^P ICA'1ION SUNMI'ITAL DA E
r!l"33
�•r
OW
ERS NAME: ILS
CONTRACfO' NAME: LIC NO:
]IVB
�S
N�
❑
CONTROLp
R 11TECT/IiNGINEER: LIC NO:
LIC
ADDRESS:
CONTACT. PITO
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG PLU MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
gI I hereby i ffrm that I mn licenced underprovisiom of Chopmr9 (commencing with
Section 7") of Division 3 ofthe Business and Pmeseions Code, and my l icease is in
full rams mice effect.
y License Class Lic.p
Date Ctomwmr
APPLIANCES -RESIDCNTIAL
JOB DESCRIPTION
l
PANELS f
UP TO 200 AMPS `
201 - IM0 AMPS
L ARCHITECTS DECLARA9'ION
I understand my plans shall be used as public reamat
SQ. FT. FLOOR AREA
�w
§/SQ. IT.
OVER EM AMPS
SIGNS 1;LECfRICAL
Licensed ProfessonA
SPECIALCIRCUIT/MISC,
Q OWNER -BUILDER DECLARATION
I hereby affimr that I ant exempt from the Contractor. License law for the
C lig l•
TEMP. METER OR POLE INST
n following mason. (Section 1011.5, Business and Prof esions Cade: Any city or county
gwhich requirea permit m courand, alter, intonate, demolish, or repair any suveture
5 prior to its issuance, also manures theapplicamharmeh permiuo file swEimd statement
rthat he is licensed pursuant to the provisions ofthe Contracmrs License Law(Chapter
POWER DEVICES
9(commencing with Section 7010) of Division 3 ofthe Business and PmllessionsCade)
m that he is exempt therefrom and the basis for the alleged I of
F P g exemption. civil penalty
Section 7031.5 by my five
hundrddolltf S500d. subjecuthe applicanuo•civil penalty of
not en Bvehundred dollarmyran).
o neroHhcpmpmy,mmyemployees with wegcsestheirsolecompenae0on,
BoninessN-N
w dmhcwons andrho she w
SWIMMING POOL ELECTRIC
VALUATION
1 1�Lt
7 7
UTLEI'S -SWITCHES-FIXjtJRE 1,
NEW RESIDENTIAL ELF.CTR SQ. IFI
STORIES
TYI' CONSTRUCTION
d Calc The Co does not apply t an,
Corelsem's Li ease L
s License Luo docs not apply to an owner of
as
mn em who
erty wh bas thenen
proorimprovesthcreom,undwhodoeaauch work hintseenalthrmit.Is
employees,provided
s,
however, the building or improvement is sold within one year ofcomplve for the owner-
psovehimprosoldwiaarenot eyewcded complfered thes wmr-,
builder will have the burden of proving that he did not build ar impmv< for purpose of
ale.).
OCC. GROUP
RES. UNITS
T
❑ Las the pacfrheprop704ELB clusivelycanaeningwith licensed
coremrn the e-)Theonvadotsm
at (Sec. ]DW, Business and Pmfessior CadeO The Contractors
QTY' PLUMBING PERMIT TEE
FLOOD ZONE
pPN
oci
License lawdaea not mpplYsranownaofpopeny who builds orimprovo thereon,and
PERMIT ISSUANCE
whocamruu forxuch projects with amntractor(a) licensed pursuant to the Contractor's
License law.
❑ I am exempt ands nm. , B & P C for this reason
ALTER -DRAIN&VENT - WATER (EA) aa..
FEE SUMMARY
BACK FLOW PROTECT. DEVICE �.
UT D Iy.F
SANITARY Y
Owner
DateDRAINS
WORKMAN COMPENSATION DECLARATION
Iheteb_ry
,❑ ffrn that l have acenificateofconwntosNGimmat ora
Y• cenif which
arkere'Compensetion lnsumnce oacenifed copy thereof (Sec. JgOq Lub CJ which
overs all employee's under this permit.
- FLOOR, ROOF, AREA, COND.
RECIi11Tp
SCHOOL TAX y
NECEII'I'p
FIXTUREn-1'ER TRAP
PARK FEE Y N
NECEI
GAS LA. SYSTEM -1 INC. n OUTLETS �^
BUILDING DI VIS NFEPS
C
Company
Company
GAS - PA. SYSTEM OVER 4 (EA)
❑ CenifiN copy is hereby famished.
PLANCHECK FEE
❑ Cenified copy is filed with the city inspection division.
GREASE/INOUSTRL WASTE INTERCEPTOR
OR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS
(This section need not becompletd ifthe permit is fur mm hundrddollvs(SIM)
or lase.)
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE
I ccnify that in the paforntvrce of the work for which this permit is issued, I"I
not employ any person in any co mer so as to become subjeet to the Workers
Aompe�.'tion Laws of Cdifomia Date
PP
WATER HEATER WNENT/ELECIR
PAID
Data Receipt If
WATER SYSTEMH`REATING
NOTICE TO APPLICANT: If, after making this Canificute of Esemplion, you should
become subject o the Workers Compensation provisions of the Labor Cade, you most
NEW RESIDENTIAL PLMIL SQ. FT.
TOTA1.
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING
SEISMil t ��
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
ELE R E
the work for which this permit is issued(See. 3097, Civ. C.)
Lender's Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
P 'MB GTEE
1 certify that I have read this application and state that the above informmion is
PERMIT ISSUANCE
IL
ALTERORADDTOMECR
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives ofthis city to enteruponthe
above-mentioned property, for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liahilidet'judgments, costs and expenses wh h may Inanywayaremeagaim said 'ty
nxyaenceidd, grantingo Nispe
.. 4[, �/ '( e/3
WWW s�'��eY`
CONSTRUCTIONT X
AIR HANDLING UNIT (OVER 10.000 CFM)
gnatum of pplicant/COntrecto Dam
EXHAUSTHOOD(W/DUCq
PAID
IIGTING UNIT (T0100,o00 BTU)
HAZARDOUS MATERIALS DES OSURE
Will the applicant m future building occupant store or handle lism no. materiel
Date 0.eceiptp
-
.T09'AL:
its defined by the Cupertino Municipal Code, Chapter 9.12, and the Hwllh end Safety
Cede, Section 25532nd?
HHA'I'ING UNIT (OVER 100,000 BTU)
VLNTILATION PAN (SIN RESID)
❑Ycs 0 N
Will theapplicanmrfuwrebuildingaccupantuucyuipmemodevims whichemit
BOILER- COMP UUP OR 100,000 BTU)
ISSUANCEDATE
thmardom eir contanunants as defined by the Bay Area Air Quality Management
CI Yes ❑ No
�nk
r "' B
BOILER -COMP (OVER 100,00) BTU)
NEW RESIDENTIAL MECII. SQ. ET.
1 have rated she hanowdeas matimm, requirements under Chapter 6.95 of the
Health At Safety Code. Sections 25505, 25533 and 25534. 1 understand that
NOVCalifornia
if ma building does not currently have a onion, that it is my responsibility m notify the
occupant of the requirements which must be at prior to iss.. of a Certificate of
Occupancy.
y 1 I~
^I Ur 1
ISSUED BY: '—
Owner or malum,ed agent Data
'
OFFICE