24877 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ° .E - TRI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. n A e J7
BUILDING DIVISION BUILDING PRDJEC'r IDENTIFICATION G L�o I
BUILDING ADDRESS: • n/ ✓✓LI.aa �nWWaA ���` SANITARY NO. APPLICATION SSUBMMALDDATE
9:2 It to OD. 0LL)r✓I r rS LOT#
OWN SNAME: �CL✓I ...ONE. 1- CONTRA R'S NAME:�I ha ,/I/ � I.IC NO:
t/� L N k/I r^ 1 N/C CONTROL#
RCHITECT/ENG R: aP55
ICNO: ADORE S: _ �Cl ❑
CONTACT: ( �/� `�� PHw O PHONE: �] Qom. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1 0'0-1 ev pC k PERMIT ISSUANCE ❑
BLD ELECT I.UMB MECH
❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RCSIUENTIAL JOB DESCRIPTIOFtSy,��
WrcM1y affirm lhmlem licensed under Provisions ofChepter9(commencing with
Y100OO force
r eo0 t of Divioion J of the Business erM Professions Code,and my license is in PANELS
fullforceandeffect.
<ZZ� License Clatis Lic.p UP T02W AMPS
E, , Data Contractor 201-1000 AMPS
-F yZ ARCHITECTS DECLARATION SQ.FP.FLOOR AR Y/SQ.IT.
'OV, l understand my plans shall N used as public records. OVER IOW AMP p
m SIGNS HI=RI AL ...,
[Was Licensed Rufesxionul OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MI ( j ,
� OOaU I hereby affirm that I um exempt from the Comments License Law for the
`F° following mason.(Seefion 7031.5,Business and Professions Code:Any city or county TEMP.METER RPOLE INST.
LL
�M W which rryuirts u permit to consume[,alma improve,demolish.or repair any swemm
�7 priorm its issuance,alsorcquires the applicant forsuch Permit file a signed statement POWER DEVIL
ye�'p0 9 mornhe erenceng with mmon to Section 7")
provisions of the Contractors License Law(CNpter SWIMMING POOL ELECTRIC VALUATION�A/!
-Lxp� or that he is
Secfion700)Jof basic far 3a.11a of the Business Profession Coda GiV
0)_m or that he isexempnherefrom it the basis for the alleged exemption.Any violation of ��—_,
Q Section 7031.5 by any applicant for a permit subjects NOUTLETS SWITCHES-FIXTURES
e applicant to o civil penalty of 00
5 Q 1,ashanfoflheve roe rtyllan(SSW). on, NEWRFSIDENHALELECTR _SQ.FT.
m n❑ Lemwneraphe the
ismomtended wi@wageamthe(See.7W,B sines gTORI TYPE CONS'IAUCfION
a will dotheandt: he Contisna[imendese Law does ntaply.?o 04,Business
and professions Code:The Contramnrs License Law does not apply to an owner of
property who hnildsvi improves thereon,andwhoawe ouch work oroff forthrough his
empltyao,pravidW that tech improvemrntserenm imcnaedorottemiforsde.IL OCC.GROUP RFS.UNITS
however,the buildingor improvement is wld within ane year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or imPmve for pm,o a of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
constr❑ Iuct the pr ject(S c.70,amexcluss n co Professions
ns C dcen The Contractor
Limens c[the project(Sec. o ano Business and Professions Code:)The Contmcmrs
Licenss Law does not apply to anownerofproperty whobuilJsorimprovntherwm and PERMIT ISSUANCE
who contracts fur such projects with acontrunm(s)licensed punuanttothe Contractors
License Law. ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason lIT TDF.FF.
BACK FLOW PROTECT.DEVICE. SANITARY YN
Owner Data DRAINS-FLOOR,ROOFARFA,GOND. RECEIPTp
WORKMAN COMPENSATION DECLARATION , SCHOOL TAX V N
❑ Thereby affirm that l have a certificate ofconsent to self-insure,an certificate of pTQRES-PER TRAP � RECEIPT'#
Weaken'Compensation larurance ora certified cap,Ucrwf(See.380),1x6Cdwhich PARK FEE Y N
r covers all employees under this permit. RECEIPT#GAS-[A.SYSTEM-I INC.40CfLFTS
Policy p BUILDING DIVISION FEES
Com❑ Cenifiedcopyisherchyfmiukhed. GAS-EA.SYSTEM-OVER 4(EA) FLANCHECK FEE
❑ Ccnified copy is Ned with Ne city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section random be completed H int permit is fmmm hundred dollars SEWER-SANITARY-STORM EA.2WPT. ENERGY FEE
orleas
I certify that in the permunammeofthe work for which this permit is issued.Ishal WATER HEATER WNFNTMI-ECTR
not cmPIOy any person in any manner so as to become subject to the Worker' PAID
ZCompensation Laws of California, Date WA TER SYSTHM/rREATING Date Receipt#
Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PI-MB. SQ.FT. TOTAL:
t^ rns
VJ become subject to the Workers Compedon provisions of the Labor Code.you must
tet-' ^�^
forthwith comply with such provisions cur this permit shall be deemed revoked. BUILDING HE �.#
W GQ CONSTRUCTION LENDING AGENCY SEISMIC FEE Eq 0
^� z Ihereby affirn that hem is a construction lending agency for the performance of O ELECTRICFEE
J O the work for which this permit is issued(Sec,3097,Civ.CJ
Lenders Name
F' Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEB
V B certify that I have read this application and state[bat the above information is
on 1. I namtocomplywith all city and county ordinances and state laws relming m PERMITISSUANCH MECHANICAL FEE
buildingen than.0 dhereby authorize representatives ofthis cityto enter upon the CONSTRUCTION TAX
Uabove- tinned pmpe y for inspection purposes. ALTER OR ADD TO MECH.
e)agree m s ,Indemnify and k ass the Ci of Cuperino against
It dities,judgme oras suite sis ay Tnwywa termagant dCd AIR HANDLING UNIT(TO 10,000 CFM)
conseyuen --ti ' perm'
` 1 ATR HANDLING UNIT(OVER 10,010 CFM)
gnat of Applicant/Con[ranor p EXIT D UST HOOD(W/OUC
PAID
HAZARDOUS MATERIALS DISCLOSU HEATING UNIT(M IW,0011 BTU) Data Receipt#
Will the applicum or fount building occupant stare or Image hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532nd?
❑Yes C3 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicanf ortvumbuildingaewpantussequipmemordeviceswhich emit BOILER-COMP(3HP OR IW,LtlO BTU)
ezardo.air conmmiaan6 as defined by the Bay Arca Air Quality Managcmens BOILER-COMP(OVER 100,001)RTU) - PAID
District?
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.FT.
1 have read the Intimations materials requirements under Chapter 6.95 of the MAR 161993
Califomia Health&Safety Code,Sections 25505,25533 and 25574.1 undersand[But
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must the met prim to issuance of a Certificate of C�I I Vr V Uf Lrl I II+�
Occupancy.
Owner or mahmi agent Data TOTAL: ISSUED BY:
OFFICE