24643 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINONG.ELEc rRICALPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24643
BUILDING PROIECTIDENTIPICATION Marv.
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL Z GAT
` IUMW� UNIT# LOT# , —Ig41 g
OWNERSNAME: £� PHONE: �� CONTRACfOR'S NAME: LIC NO:
NIC CONTROL N
ftCHITECT/FNGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: " v.: - --.. .-r• -, :, . -;,:. BUILDING PERMIT INFO
QTY.�'c,' �;'ELECTRIC PERMIT:':I. `�:-.. '•IftPEE v.;, .;.•
"x.e.".' ; "axx" BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
WOwzOO Ihereby uff Division
amlicenxdunder
smdPeiansofCCooh,and
mmeneing with
WOO Section a sII t of Division J of the Businea and Profession Cade,and my license is in pgNELS
aVF full incessant eft
oI Data Oms Con mc4�rTGl UPT0200 AMPS
A NAS JILy 201.H)WAMPS
F y_Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA SISQ.FT.
Cz_C I mdentand my plans shall:used as public rcamds. OVER ELL AMPS
F ns f-W SIGNS ELECTRICAL D IN
Q f� Licensed Professional
cepRi6 OWNER-BUILDER DECLARATION SPECIAL CIRCUFIMISC. nn M
KOiUF I hereby affirm that 1 am eac n"tram the Connector's Liceme law for the W3Wr<n following reason.(Section 70JL5,Businass and Professions Cade:My city m county TEMP.METER OR POLE INST.
I_v-O J which requires a permit to construct,altar,improve,demolish,or repair any souctuse
CWa� to its issuance,also the applicant for such permits file a stand!statement POWER DEVICES
prior requ'uw pp Penni gtted
W z 00 that he is licensed punuan,to the povisionsof the Comm e.Lt...laws(Chapter
as 1' 9(commencing with Section T00a)of Division 3 ofthc Bminasand Pmftssiom Code) SWIMMING POOL ELECTRIC VALn,uro.�
W �* I -
$p, or that he iseamptNerefromend the leads far the alleged exemption.My violation of OUTLETS-SWITCHES-M(TURES �'
L Z Q Section 7031.5 by any applicant far a permit subjects Nan
e applicant an a civil penalty of
�_O rat mI.nhnrofhundred dollars
rmym). NEW RESIDENTIN.ELECTR _SQ.Fr. STORIESTYPECONSTRUCTIOT
:g ❑ I,mownerofl:pmpactum is otimanye(SwiNwalforsalei(See. 10M.Busarion,
a3- and Prlla lhssi...Code:she Cmeiscam's Lmd,orawdrives 1ale ply to, 4,Business
and Professions Code:The Ca therans License Law such
oat apply m rt owner iof
s
a"pro,employebuildsorimpmvratherton.andw:sh,not hwoh Nmmlredfeeor We.
OCC.GROUP RES.UNITS
ownemployees,Provided dust such inti is said
dwi arenot itendedoroffertdfarsale.lL
bowevm,thebuildinguimprovementissoldedidnor, Yet or improveifo,Neowner- TOTAL:
builder will have she burden of proving that he did not build or improve for purpose of
❑ Las mwnerpl Ne PropmY.om exclusive) onuactin Nlicrnt,conuactomo QTY py t!_r ,PLUMBDJG PERMIT Y-F. ,YF FEE'-k ROOD ZONE APN
Yc Bwi x: :PER
construct w Psajm(Sec.](44,Business and,who boas Code:) Inc Convectors PERMIT ISSUANCE +
License law does not app I y w w owner of property who bui Ids ar i mpmvn thereon,and
whocontracw fmsuch pmjccawich.conrtabma)licensed pursuonuo the Contractors ALTER-DRAIN&VENT-WATER EA) 1" �'> +'"w•
Lice me law. ( J'_.,,,.T, i2FEE_ SUMMARY�•, n'r1.;y2�%
❑ 1 am exempt under Sec. .B&P C for Nis moan BACK ROW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date DRAINS-BOOR.ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have o certificate ofcomenfto self-imum,macenificate of I7XIIIRES-PER TRAP RECEIPT
Worken'Compemation Insurance or a certified copy thereof(Sm.380,Lab C.)which PARK FEE Y N
covers all employee's.Mer Nis permit n GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT is
Policy P.Q- �SQIC-7�3 BUILDING DIVISION FEES
CI Cert P� �'�'�� M FJ� ' GAS-E,.SYSTEM-OVER 4(EA) M&NCHECK FEE
❑ Certified copy is Aertby famish,.
0-Certified copy ie filed with the city inspection division. GREASFlINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rand mabecompleled i(Ne pemtil is forms hundred dollan($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees.)
I certify that in this performance of the wants for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any Ryan in any manner so m in become subject to the Workeri PAID
Cam,stroaonlawsof California. Data WATER SYSTEM/TREATING Data Receipt#
0 z Applicum
z0 NOTICE TO APPLICANT:ILaher madou,nu Cmiificamof Caemptin.you should NEW RMIDFNTTAL PLMB. SQ.FT. TOTAL:
L VJ became subject 10 t:Worker's Comperoatian provisions of t:labor Code.you must �r
Y 7 fowiNcomply with such h
provisions or N,p nom,ell be deemed revoked. BUILDING FEE
M
1 Q CONSTRUCTIONLENDING AGENCY SEISMIC FEE
I:rcby amrm Nat t:rc is o consnuc,i.lending sil for the performmos of
V O the TOTAL: ELECTRIC FEE
Le work(m which This permit is lou,(Sec.309],Civ.C.)
(L r Lenders Name '..y:.r -1jxS:,y.{, - exv_*.!..5..••'ai+aI J s YsJiR'e PLUMBINGFEE
ISMer'e Address QM.jX-,.,y �MECHANICAL-PERMITIT ;�v!^.ts.3� ^A'�.. FPE':�v
0 1 certify that I have mad has oyplicuu m a,swat but the.hove Information is h "s;'ex'-"'e=r"'M"«. a.•.:.y.�!! ;$'..sv -,.- 1
>. 1 correct. I agrce to comply with all city and county ordinances and state laws mleting m PERMIT ISSUANCE MECHANICAL FEE
building mmavutian.and hembysudarir<mpmsenwtivesof Nlsciry w enmrupan the y CONSTRUCTION TAX
V z above-mention,proparty for unity and lobe, . ALTER OR ADD TO MECH.
(We)u gins to ave,indemnify and hie may in a the airy of a againino ad City
Iiabilitiesj,gmcrustracosts ed,expenses which may in any way accme.gainnsalJ City AIR HANDLING UNIT(TO IO.Uq)aFM7
in consryueme of the granting of this permit.
;79'a� AIR HANDLING UNIT(OVER IO,OW CFM)
'^lam
Sigtawr 9a wfij7Ca.tmr Data EXHAUSTHOOD(W/DUC) PAID
HAZARDOUS MATE LS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt N
Will the applicant or future building occupant such,or handle hemlous material HEATING UNIT(OVER I W,Wd BTU) TOTAL:
a defined by the Cupertino Municipal Conn.Chapter 9.12,aml the Health and Safety
Code.Section 25532(.)' VENTILATION FAN(SINGLE RESID) J
❑Yes ❑Na
ISSUANCE DATE
Will the upplicumor future buildingmembart useequipmenmrdevims whichemit BOILER-COMP(3HP OR IW."BTU)
haamduus air conmmitwnn as defined by the Bay Arta Air Quality Matwgement BOILER-COMP(OVER IW."BTU) - d � 2%
District]
❑Ya ❑No NEW RESIDENTIAL MECH. SQ.IT.
_ I have mad the hvardaus materialh rtl.mnams under Chapter 6.95 of the DEC 29 1992
Culifomia Health&Safety Code,Sections 25505.'3533 and 25534. 1 understand that
iR.pantbuilding dcee not currenrabno which
m st be that Prior to smunce oility to notify the Cl i f
occupant of the es not memo which mut:nen prior m issuance of it Certificate of
Occupancy.
Owner or a.moo,ed agent Data TOTAL: ISSUED BY:
OFFICE