24992 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUDAHNIJ, A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL n �I (�n
IIUILDING PROJECT IDENTIFICATION G L� J G
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMffI'ALDATE
�'GJ iss) UNIT# LOT is e-tisslilk-As
OW - 4 HO CONTRACTOR'S NAME: LIC NO: NXCONTROL#
R aafftw4few 9846
ARCHITCLUENGINEPR: LIC NOESS:
flN/1✓ /WQ El
D
MMO
T —
CONTACT: PHONE: `
QTY. ELECTRIC PERMIT FET, BUILDING PCRMIT INFO
oFyDC ELECT PLUMB MECII
PERMIT ISSUANCE El 0 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL sss---PPP JOB DBS(y[MON
^yz I hereby affirm l umlicensedunder provisiunsnf Chapter')(commenting with S
00E Section 7000)of Division 3 ofthe Businessund Professions Code,end my license is in PANELS
KUU fullfume amt effect. 846 DfFtitO
F6.Zty License Class Lic.# UPTO2W AMPS
us D y Dare Commctor 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
ZC1t Z ARCHITECTS DECLARATION OVER IOWA PS
CZ—,G I understend my plans shall h used as public records.
r,y F W SIGNS ELECTRICAL
g�E� Licensed Professional
K OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIS
0:110.O4U 1 hereby affirm that 1 am exempt from the Commends License Law far the
0 following memo.(Section 703 1.3,Business and Professions Code:Any city or county TEMP.METER OR POLE.I
on 1 which requires a permit m c.marro L site,improve,demolish,of repair any structure
fl¢� priorte,its ismance.also requires the appllmnlfor such Permit file asigned summeat POWER DEVICES
µl DO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
L o-o�' 9(comosesing with Section 7")of Division 3 office Business end Professions Cole) SWIMMING POOL ELECTRIC ` VALUATION
or that h70315mpnhercfrI ant f the baspearmtanhects the applicant
n.Anytouched
priory of OUTLETS-SWITCHES-FIXTURES
gCCl'oa7p31.5 by ve anyapplicam fore pertnit subjects the apPlicannoacivil penalty of V
not morcthan ofthedreddollarmyemp. NEW RCSIDENf1ALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
�E ❑ I,mowld.tldhe operty,enearm eadedmoiferegcsnstheirsole compenmtion,
4 will do Wewmk,Cad the stmaare ismmi Licm oLawdosnot 1phr.an Basins
and Professions Cute:The Conuecmr s License Lew does not apply m an owner of
propenywyees,pdsor videdtroves aimclirepurverems messuchwurk eduaroelfnr formic.
roughbis
m�mmic.I, OCC.GROUP RES.UNITS
however,
tyees,pingori polve ant iss sold
wit me not inmndedoraffem5 foe role.1f.
however,the
avet a Nolen
issolde did not yearofcompletion,theowner-
TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,oeownernfthepropeny,amexclusively contracting with licensed contracmrsm QTY: PLUMBING PERMIT FEE PLOOU LONE APN
construct the project(Sec.7(A4,Business and Professions Code:)The Contractors
Licenx Lewdocenot apply roanownertf progeny whobuildeorimproves thereon,end PERMIT ISSUANCE
whocommnsforsuch projects with acotdmctor(s)licensed mountain to the Confiscates
License Law. ALTER-D 4!VA E (EA FEE SUMMARY
❑ 1 em exempt under Sec. ,B&PC for this reason BACK FLU PILO :C�'T D�V F. SANITARY OUTSIDE N
Owner Dare DRAINS-FLOOR,ROOF,AREA, O RECEIPT'#
WORKMAN COMPENSATION DECLARATION Mt1n--ee�n SCHOOLTAX Y_N
❑ Ih<rchy affirm thsrlheveecenificum of consent malt-insure.ora mnificam of FIXTURES-PEr{A#y�p RECP.IFT#
Workers Compersminn lnaumnce orecenifiedcopy thereof(Sec.3g00,Leb CO whits P Y
RK FEE N
rs all employee's under this permit. GAS'EA.SYSTEM.I INC.4 OUTLETS — RECEIVE,#
Pylic.# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4IRA) PLANCHECK FEE
❑ Ccrifiedcopyishrod,fiumished.
1 ❑ Cenifed copy is filed with the city inspection division. GRHASFJINDUSTRL WASTE.INTERCEPTOR GRADING HE
CFRTFFICATE OF E%EMPTTON MOM WORKERS' GRPASETRAP SOILS FEF.
COMPENSATION INSURANCE
(Thisxcocm neednatbe completed ifthe permit is fafameloodred Aollas(SIM) SEWER-SANITARY-STORM EA.2MFT. ENERGY FEE
or less.)
Icenifythrt in the perfoemaux,tfine workfor which this pennit is issued.)shell WATER HEATER W/VENT/ELECI'R
not employ any Person in any manner so as to become subject to the Workers PAID
Compm
enfitn Lawrof Califomia. Date WATER SYSTEm
ETREATING Dole Rcipt#
O 0Applicant NEW RESIDENTIAL PLMB. SQ.PT.
0 NOTICE TO APPLICANT:ILafer making this Certificate ofF emption,you should TOTAL:
CA hoemac subject to the Wormers Compensation provisions afthe Labor Code.youIE
forthwith comply with such provisions or this permit shall be deemed mvoko L BUILDING FEE /rs
[a SF.ISMICFF.E
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a commucfioa lending agency for the performance of
U O the work for which this Permit is issued(Sec.3097,Civ.C.) I TOTAL: ELECTRIC FEE
Isadcr's Name
kLPEP.
O Lenders Address QTY. ' MECHANICAL PERMIT FEE PLUMBING
1 cenify that I have mad this aPpliclum.add store that the above information is - MECHANICAL ME
coned.Iagrcewemidilywhibldicityandcaunty o iumnees and state laws xlmm,to PERMIT ISSUANCE
�-' to building construction,and hereby audience represemurivesoffhis citym enterupon Be CONSTRUCTIONTAX
U 4 above-mentioned property for inspection pugwses. ALTER OR ADD TO MECH.
(We)agree to mvc,indemnify and keep harmless the Cu,of Cupertino against
liabilities,judgments,costs and expenses which may in any way secrueegains said City AIR HANDLING UNIT(TO)0000 CFM)
in comequence of the gaming of this permit. s'
J/NI � AIR HANDLING UNIT(OVER 10,0110 CFM)
e4mfgnawm of #plicmVContmcm D e
EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HI3A9'ING UNIT(TO 100,000 BTU) Date Receipt
Will the applicum or furore building occupant store or handle immortals material
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safe,, HEATING UNIT(OVER 100,1%)11 BTU) TOTAL:
Calc,Section 25532(e)7,.
❑Yes ❑No VENTILATION FAN(SINGLE REBID)
- ISSUANCE DATE
Will theapplicmtorfutumbuildingacupmt useequipmemordevicessehich emit BOILER-COMP(3}IPORIW,000STU) PAID
FT��
hazardous Ar contamirenrr M defined by the Bay Arm Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A 9 D
evict?
❑Yea ❑No NEW RESIDENTIAL MECH. gQ.FT.
1 have read the hnardous moerials requirements under Chapter 6.95 of the APR 211993
Califomia Health&Safely Code,Sections 25505,25533 and 25534. P nndcrstand that _ '^ y
ur VUrtr�
if the building does not currently have a tenant.that if is my responsibility to notify rhe '�l.
execution,of Ne requimmems which must Ite met prior to issuance of a CeAt
ficau,of
r Occupancy.
Owner or mthodzed agent Date TOTAL: ISSUED BY:
OFFICE