24920ADDI ICANT Tn PD I IM INPORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINCaBLECTRICAL
CITY OFCUPERTINO APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
w 0
PERMIT NO. 249
•LJ9
BUILD/INIG2ADDRESS`: 1 (� 4 ,���s ��5a �, (� ��,�.
I tf355 i� `oma 1 il- ` W o `W oe I UNyIT, . LOT #
SANITARYNO.
APPLICATION SUBMITTAL DATE
4A
OW NAME: - PHONE:
CONTRACTOR'S NAME:. LIC NO:
NIC
CONTROL #
L
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG L PLU MECH
-
PERMIT ISSUANCE
LICENSED CONT'RACTOR'S DECLARATION
1 hereby affrmthat I amlmonsed underpmvisionsofChapwr9(commencing with
APPLIANCES -RESIDENTIAL
)OB DESCRIPTION
Section 9000) of Division 3 of the Business and Professions Code, and my license Is in
fame end ¢flet F-
License Cn Lic.#
PA .LS
UP 0280
Dam Ccoraaor
ARCHITECT'S DECLARATION
201 0 P
SQ. FT. FEDORA 'A
d/gQ. F1'.
OVER 100 M
1 undemmnd my plans shall be used as public records.
SIGNSEL TRICAL '
Licensed Professional
' OWNER -BUILDER DECLARATION
SPECIAL C CUIT/MISC. �
I hereby affirm That I an exempt from the Commemrs License Law for Ee
following reason.(Section 9031.5, Business and Professions Cale: Any city or county
TEMP. METENR
0,0
gT.
which requires a permit to construct, aper, improve, demolish, of repair any smuc[ure
Fourth its issuance, alsorequires the applicant for suchpetmi[ to file aligned statement
POWER DEVIAil
ZC
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 9000) of Division 3 of the Business and Profusions Code)
or that he is exempts somfrom and the basis mount alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
SWIMMING POOL ELECTRIC
SWITCHES -FIXTURES'
VALUATION
015
�/��rr��
NEW RESIDENTIAL ELE,CTR S Q . FT
of mom the. five hundred dollars (5500).
❑ I, asownemfteprhparty. ormyemployeeawi[hwegesasteirsolecompemaion,
rw� 1' ONS RUCTION
will dothewmk,and[hesitation, isnot imendedmoffenedf.rsam(Sol. 9044, Business
/r—O
and Profeuioms Cade: The Common., I License Law does not apply to as owner of
progeny whobuildsonarproves[hercoa, andwholms such workhimselforthroughbis
wnempluyees, providedtet sucM1improvcments erenotimm�dedoroffercd forsale. if,.1
however, the building or improvement is sold within one yearofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I, as owner ofthe property, aexclusively contracting with licensed contractors to
❑ m
C . R 'S.0 ITS
a/ #-Y ry /q
Oe• d L/
QTY. PLUMBING PERMIT PEE DJ
arm ti
onstmet the project (Seo. 9144, Business and Profusions Cod' The Con..
License Lewdoes not applytoanownerceproperty whobuildsorimprovu[hereon,and
1
PERMIT ISSUANCE l �.'aaa,
wh.chn[mcafo... chprojectswith acohraemr(s) licensed parsuonlmlhe Conlrndois
License Law.
( ) I'�-
ALTER - BRAIN &VENT -WATERER
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
❑ 1 you exempt under Sec. , B & P C for this mason
SANITARY YN
RECEIPT#
Owner Da1B
WORKMAN COMPENSATION DECLARATION
❑ Ihereby affirm that l have a certificate ofconsent to self -insure, or a cenificate of
Workera'Compense[ioninsurance orecenified copy thereof (Sa.3g00, Lab CJwhich
covers all employees under this Inerrant.
Policy #
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOL TAX YN
RECEIPT#
IXTURES-PER TRAP �I
PARK FEF. YN
RECEIPT #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
GAS- EA. SYSTEM -OVER 4 EA)
PLANCHECK PE
-rylalay
trifled copy is hereby furnished.
OREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Codified copy is filed with be city inspection division.
CER'1TFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Thisseculon need nm he completed ifthe pemlit is fur one hundred dollars ($100)
ones'.)
I certify tat in the performance of the work for which Eis permit is issued, [shall
WATER HEATER WlVENT/ELECPR
not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of Califnnia. Date
PAID
Date Reccipt#
-
WATER SYSTEMITIMATING
Applicant
NOTICE TO APPLICANT: If, after aking this Cedificeteof Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subjectto the Workers Compensation Provisions of the Labor Code, you muse
forthwith comply with such provisions or this pioush shall IN, deemed revoked.
BUILDING FEE kid
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction leading agency for Em perforrmene of
the work for which this permit is issued (Sec. 3099, Civ. C.)
T A
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
Lender's Name
Landis Address
' 1 certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating no
PERMIT ISSUANCE
buildinge amo a hurt and hereby motorize monescmebses hf this city to ti mruphn the
above-mentioned property for inspection purposes.
L'fERORADDTOMECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any wayarome againstseid City
AIR HANDLING UNIT (OVER IO,OCPM)
onaequence.Eegr�sho `ou—ngemit.
r
/.� DP,C � 2L 5,
EXHAUST HOOD(WMUCID
PAID
gniureof Apel' anUContraaor ma
HEATING UNIT (TO UNDER BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date ReceiPt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
W ill the applicant or future building overprint slue or handle hazardous material
as defined by the Cupertino Municipal Code, Chepmr 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID) Ilfifk
Code, Section 255J2(a)P
11Ya E)No
ISSU 6, fil
ANCBEVV
BOILER - COMP (3HP OR 100,000 BTU)
Will the applicentor f.turebeficeg by the Bay equipment Quality Management
ardous xir conmmirlants as defined by to Bey Area Air Quality Management
JU 221993
BOILER - COMP (OVER IOO,1Kq BTU)
istric[T 1:1ElH,
Yea No
materials 5505, 25533 .it 25 Chapter 6.95 of the
I have read the Safety 1 understand Eat
lthdo & Code,
Californiaheulbuilding cur Code, Samara 25505, 25533 and
Cil Y Uh riVNtli / j
NEW RESIDENTIAL MECSQ. FT.
responsibility
of currently have a tenant, that it is my responsibility to notify the
if the building does not
occupant of me requirements which must be mei prior to issuance of a Cenifcam of
m
Occupancy.
ISSUED BY'
Owner or authorized agent DeteCCU
SID
OFFICE