24712 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL DING-MECHANICA. PERMIT NO. �a I .a a�
APPLICATION/PERMIT PLUMIIINC-MF.CHANICAI. L 4 / L
BUILDING DIVISION BUILDING PROAECTIDENTIFICATLON
BUILDING ADDRESS: LOCM --fly_ SANITARY NO. APPLICATION SUBMITTAL DATE.
aJ�R��[C a YG UNIT# LOT#
OWNERS NAME: PHONE: CONIRAC70R'S NAME: ky�./�/ LI`/NO: N/C CONTROL# SJ
ARCIII'fECI'/IiNG114 I4: N LI Al iSSS:/WnSN 1 r 1 I V I CI t9-J. ❑
<bAWA T9144 4'5'6)P&&,.57$0 Q.�, ELECTRIC PERMIT EEL? BUILDING PERMIT INFO
9 .J BLDG F.LEC PLUMB MECH
PERMIT ISSUANCE ""� ❑
LICFI.ISEDCONTRnder Wo iME of RATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
pp;Z Thereby affirm@ml3 of eBusinss praviamesof Chapter and mmeneise with
�O�
full f�me0wdeffeof Dtvision3 of the Busineas111and
���Pmfessinns Code.and my license is in PANELS I�k�i�l
License Con, UP T02W AMPS IN
mQy Date Comracmr 201-1(X0 AMPS
f'M ARCHITECTS DECLARATION - SQ.IT.FLOOR AREA $/SQ.FT.
ZOo, lund � Play�ha cuxdas ubJl,�rs�rJa. OVER IOOO AMPS
OZ—D Y/rw"CSL �f8➢) II
rMlp tW SIGNS ELECfItICAI, rJAI -e. FT
Q L j Licensed Professional i C l.�J��-NX r 1
nQ OWNER-B RDECLARATION SPECIAL CIRCUI'FMISC, p''� ^�(
d OyU I.hereby affirm that I am exempt from the Contractors License Law for the ` t k"
¢131r-m fallowing reawn.(Section]031.5,Business and Professions Cede:Any city or county TEMP.METE
OR POLE INStI IL. SRR, {{{{
ka0¢ which requires.permit tomnstrvc6 alter,improve,demolish.or repair nnyswetum
zw¢� prior to its issuance,also rtimicsthe applicant for such Permit torite asignedidiarnarm POWER DEVICES DATE
y1 Ky pthat he Is licensed pursuant to the provisions of the Contrwtor's License Law(Chapter
L X.T 9(commencing with Section]IX)()uf Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
WM, or that her is exempt therefrom and the basis for the alleged exemption.Any violation of OVfLETS-SWITCHF.4 FIXTURES,
1��y�Oa�
Section 90315 by any applicant for a p,rnitsubjects the applicant to a civil Penalty of ..
Kxx Q oat mart than live hundred dollars($500). 29 .
m ❑ 1,mnwnemftheproperry,ormyemployeuwiTh wages astheirsolecompenwtion, NEW RESIDENHALELECIR _SQ.FT. STORIES 9TPECONSTRUCFION
y will do the work.and menrairmeisnot intendedaroffered fmsale(ht7044,Business 7
and Professions Cade:The Contractor's License Law dao not apply to an owner of 1
pmpeny who builds or improves thereon,and who does such work himself or through his
employeea,pmvided the such improvememsarena imendedoroHertdfmsale.IL OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearnfwmpletion,the owner- �� �..'3
builder will have the burden of proving that he did not build or improve for purpose of C/
oile.).
❑ L as ownerofthe proper,smexclusively contracting with licensed contractors toQTY. PLUMBING PERMIT FLEE FLOO�(DZONH APN
construct the project(Sec.7JPL Business and Professions Cale)The Conuacmr's PERMIT ISSUANCE N/A
License Low does not applyman ownerofpropcnywhobuilds orimprovestherean,anG
whocotnracts forsuch projems with a couracmr(s)licensed pursuant to the Cnnvucon s
License Law. ALTER-DRAIN&VENT-WATER(EA) TEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason Ts—
BACK FLOW PROTECT.DEVICE 1 I, i
SANITARY Y N
Owner Data RECEIPT a
DRAINS-FLOOR,ROOF, COND.
WORKMAN COMPENSATION o(co DECLARATION SCHOOLTAX V N
❑ ers'Co peousaffintion Insuve a rance
miremenfcomemmurf(Snsure.0r Lab C.))ate ofwhich FIXTURES-PER TRAP RI.CEIPTp
Worken'Cumpensatinn lnaurunce ora<eniBed copy 0tereof(Sec.3g00,Lab C.)which PARK PEE Y N
coveoallemplo a' un er thiel T R1:CEI #
y ��gS rel GAS-EA.SVSTCM-I INC.40UTLCTS
Policy# r_5'� A 1 17��� BUILDING DTVI ION PEES
Company ns LSO GAS-EA.SYSTEM-0VER 4(JUG PLANCHECK Mr, O
❑ (snifed copy is hereby famished.
�CeniOed copy is filo.)with Ne city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERq'IFICATI OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section head not be,campleTedEm.pemrit is(Drone hundred dpllvs(4100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenifythvtinthe perumtarceof Ne work for which this .it is issued,lshsll WATER HEA'1'F.R W/V N`TAELECTR
not employ any person in any manner w as to become subject to the Workers' PAID
Compensation Laws of California. Date WATER SYSTEMOREATING D Receipt If
la
z Applicant
z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.PT. TOTAL:
r � become subject to the Worker's Compensation provisions of the Labor Code,you must
F' > forthwith comply with such provisions or permit sholl be restated revoked. BUILDING FEE
Wry Q SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is i construction(Sm.3 lending agency fm Ne performance of
U O �, �� TOTAL: ELECTRIC FEE Ia
Ne work for whi� his ria issued(Stu.309],Civ.CJ O
u. Lender's Name. PLUMBING FEB
0 F" Lenders Address � QTY. MECHANICAL PERMIT FEE
U 1 certify that I have read this application and state that the above Information is r� MECHANICAL F
>. entree[.l agree as comply withal]city and county ordinances and state lawsrelatingm PERMIT ISSUANCE
t150 building construction,and hereby suborder repreeentativesofthi.cit,to enter upon the CONSTRUCTION TA%
U z above-memmod!property for inspection proposes. 1 ALTER OR ADD TO MECH.
(We)agree m save,indemnify said keep hmmleas the City of Caper irm egainn
lishilities,judgments,costs and expenses which may in any way werusagainat said City AIRHANDLING UNIT(TO IO,WOCFM)
in co equen a of Th grand-^ng of this permit.
AIR HANDLING UNIT(OVER 10,000CFM)
Signature of Applic ontmctar ypyQ=Da/i—e E%IIAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.00)BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous tated.W
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the I lealth and Safety HEATING UNIT(OVER 1OL"61V7
Cole,Section 25532(a)1�w3,,,,�/// VENTILATION FAN(SINGLE RESID) w+
13 Yet XNu
WilHheapplicwt orfuwre buildingrt'cuWmaxwipmem ordevices whichemit
ROILBR-COMP(3TIP OR 100.000 BTU) ISSUAN DATE
M1arardoua air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU))
lack' k PAID
❑Yea yQ No NEW RESIDENTIAL MLCR—SQ.FT.
I have read the haaardous materials requirements under Chapter 6.95 of the
California Health&Safely Cole,Sections 25505,25533 and 25534. I understand that FEB 11
if The building does not currently have a tenant,that it is my respardhilirym notify the 1993
Occup: t of th require encs which must be met prior to issmrce of a Certiricam of
°I T ''y' CITY Of r u,iliw
Ovincr or authmrieed ag Date ISSUED BY:
OFFICE