24990APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO•-' A-
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT' IDENTIFICATION
PERMD'NO.
24990_
B ILDING ADDRESS: /
t1l0 a— b*aUN1;a LOT#
SANITARY NO.
APPLICATIONSUBMITTALDATE
(A",-�
OW • ' N PHONE:
1*1
CONTRACTOR'S NAME: LIC NO:
'
N/C
❑
CONTROL#
RCI INbw—LIC NO:
ADDRE
CONTACT: PHONE:
QTY. ELECTNICPIiR FEE
BUILDING PERMIT INFO
IX- PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
lnfscommencing with
surs
Section a fDislesn 3 ofthe Business and Professions Code,and my license is in
APPLIANCES- ?SIDENTIAt
�'000S
RIHONIheuhydfi
``
full force and efed.
License ClasLic. #
P 00AMPS
j111
Data Cmun
W. I" AMPS
ARCHITECT'S DECLARATION
I undco mat my plans shall be used i s public resents.
OVER 1000AMP5
SQ. FT. FLOOR AREA
�sg
$/SQ. FT.
GN ELE A
Licensed Hufcssienal
C.JC/
PE 1 CI IT/A11
OWNER -BUILDER DECLARATION
I hereby affirm that 1 an exempt fmm the Conunno Licence for the
METER POLE INST.
following rmsoa(Section o
Business and Professions Code: county
which reyuima n permit to mnmuum, dmq improve, demolish, er .spar any .datum
construct,
pnomo its iesmice,alsorequircatheopplicant formth permiuO flea signedstamment
BR VICIS
that he is licensed pursuant to the provisions of the Conammr'a Liceasc Low (Chapter
9(ceantruingwith Section 7")or Division 3.1' the the Business Professions Code)
or that he is exempt therefrom out the basis for the alleged ex emptian.Anyviolationof
Sec<,0,L5hyany might -fore permiuubjectsthe applicannoa civilpenaty Of
S MING POOL ELECTRIC
I LUATION
al
OUTLETS -SWITCHES -FIXTURES
an five hundted dollars (5500).
wnetoftheMro ay.ormyempioyoeswiNwagesatheirselecomNEWRESIDENTIALELECfR
_SQ.FT.
STORIES TYPP.CONSTRUCTION
I
Jork, undthestruciure is nm intended oroffered forsale(Sm. 91144, Beseridinns Code: The Contractor's Lianse Law does not apply to an rte of
propenywhebuildsorimpmves Neuon,mdwhodaesuchworkhimsclf roughhis
not esondeampl ud theow. T-
wnemploy«.,provided improvement
buwwmillhathe building burden vementisaolde didnoncyeao, improefor,eownet-
builder will have the harden of proving than he did not build or improve for purpose a(
C.fiR U R' 1
n I `��
v IILJ
T
QTY. PLUMBING PERMIT FEET
ale].
❑ sunwouroffic connecting
pAlff ZONC N
C
Coditnaedcoormtorvo
umswctthe project (Sec. 9044, Business and Professions COJe)'@e Cormorant's
Iawdofoens anords)—
wanectoonftrporcomper(rtsy)
awith
PERMIT ISSUANCE l
o
who contractsuc h#projects licensed Factor, to the
icensedpursmunthe Contractors
License I..
ALTER - DRAINAt VENT-WATER(EA)
FEESUMMARY
❑ 1 am exempt under Sec. , B & P C for this rcasoo
BACK FLOW PROTECT. DEVICH
OUTSI B
SANITARY Y N
RECEIPT#
Owner Dam
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATIONDF.CIARATION
SCHOOLTAX YN
❑ Thereby a(frm that lhaveacertificam ofcomrntmulf insure, mecertifcem of
Wmken Compensation Insurance orecmifeJ copy thereof (Sec.3800, Lab CJ which
RECF.IPTp
FIXTURES-PERTRAP
PARK ME Y P1 N
coven all employee's under this permit.
Policya
RECEI Y
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIV ION FEES
Company
GAS- EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE is"a
❑ Cenificdoo,khercbyfumimed.
GRFASErINDUSTRL WASTE INTERCEPTOR
GRADING TLE
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY /
ffnissection need not be, completeddNepeomit is foron, hundred dollars ($100)
m less.)
WATER 14BATFR WNENT/BLECTR
I certify that in the Nr6rmance of the work for which this Permit is issued, )shall
not employ any person in my manner so as to become subject to the Workers'
PAI
Compensation Lawsof California. Date
WATER SYSTEMnRFATING
Dae Receipt#
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. ET.
TOTAL:
become subject to the Workers Comp anci icn Provisions of the Labor Code, you most
forthwith comply with such provisions or this permit shell be deemed revoked.
BUILDING ME a"a's,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is o construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Co. C.)
L.
ELECTRIC FEE `
larder's Name
QTY, MECHANICAL PERMIT FEE
PLUMBING FBE #r
Lender's Address
1 certify that 1 have mad this application and state that the above information is
marc,. logreemcomply with ell<iry anJcomty ordinances and aatelewa relating to
PERMIT ISSUANCE I C/�
MECHANICA FEE
buildingcanstunion, andhereby emhonu rcprcsentutives ofthis city reenter upon the
vbove(mentioned property for inspection
ALTER OR ADD TO MBCH.
CONSTRU ION TAX
keepmes.
(We) ague m move, indemnify. keep harmless the iry of Cupainst against
which yin my #esus against City
liabilitics,jud nemag
AIR HANDLING UNIT (TO 10,(X)0 CFM)
i fithnses
in coni of theg nti fl permir.
s.
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD(W/DUCD
PAID
Signal eof Applicant/Comm rDam
HEATING UNIT (TO 100,000 BTU)
H, ARDOUSA I'FBIALSDISCLOMJ
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
AL:
Will the applicant or future building occupant store or handle hazardous material
as defined by rhe Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
❑ Yes ❑ No Code,Seto25532(0)?
BOILER - COME (3HP OR Har" BTU)
)
yA pq�/E
j
V
Will theapplicaut orfuture buildingoccupnnfusee ui mntordevicswhichcmit
daus air roaminanis as def.ed by the Bay Amv Air Quality Management
°zerm
strict?
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MGCII. SQ. FT.
❑Yes ❑ No
APR 2 0
1 have read the fetyCo e, materials 5505, 2 533 under Chapter 695 of the
& Code, Seniums 25505, and 25534. I understand Nm
6� I Y
!! (Jr uurcn
if.CalifornialHealth
o, t it is to notify
sithe building does not have a mount,et o is my reuance
1
mmuscurrently oility
Occupant of the requirements which most be met poor to issuance of RCenificvm O(
of
Occupancy.
ISSUED BY:
Owner oramhonzed #gem Dom
T
OFFICE