24729APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO I 't' "' LA,
APPLICATION/PERMIT PI.UMBIN J•MECHANICALIFIIC24729
BUILDING DIVISION tlUILDING PROJECT IDENTIFlGATIDN
I'LRhII'1'NO.
^ 7 2 9
G a� G J
BUILDINGADORFSS:
SANITARYNO.
APIY.ICATION SUBMITTAL DAT.
S�L �`/•-' UNIT LOT.
72,k—c{3
OWN SNAMF.: PHONE:
CONTRA OUNA LIC NO:
G `u ��'� • ����
^
N/C
CUN1AOLa
AR H CpENOINEER: LIC NO:
ADDRESS:
Lesesti�L�aIq C -t �
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB E
PERMIT ISSUANCE `weer
1
LICENSED CONTRACTOR'S DECLARATION
1herebyvfrim Nm Imahmnsedinderprevismumf0mucl9 mommmcing wish
Senion7t",of Division Sof the Business and Preferment Code and my heame, is in
APPLIANCES - RESIDENTIAL
�JaOtB �D�ES�CRIPTION
Fla
PANELS
lull fora rd.flac'.
License Chas Lic.0
UPT02MAMM
Dau Contract '
m
ARCHITECTS pECLARATION
I undmuM my Plain shall be used so public records.
201 - I"AMM
SQ. FT. FLOOR AREA $/SQ. PT.
1�
(XXMPS
OVER IIA
SIGNS ELECTRICAL
Licensed Proussmrul
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am <aemPa from thc Ci nbwurs License Law for the,
following nano. (Section 90315. Business and Profusions Cade: My city or mumy
SPECIAL. CIRCWT/MISC.
: I
I V
TEMP. METER OR POLE INST.
which minutes a pcmtit n counter. alter, improve. derrolisR or repair any sbuctue
prim to in issuance, also ¢quint the applicant ler such Permit file reigned moment
TE
POWER DEVICES
that he is lammedn
puumthe t to Provisions of the C.,or's Lt. law (Clamber
9(comne m$with Sccaion 7") of Division 3 of the Business and Profecvimer Code)
AL ATION
SWIMMING POOL ELECTRIC
or But he is 'crept therefrom and the hatis fee the allegedeseennum. Anauon of
Section 70313 by my applicant for a permit subjects the applicant n •civil prnalav of
OUTLETS. SWITCHES -FlXTURES
nm nus then five hundred dollen (S500).
❑ I.uownerolNepreperry.ormyemploymwithwagnuNeirmleonmpetwsion,
NEWRESIDENTIALELECIR_SQ. FT.
STORIES
TYPECONSTRUCTIO'
\ eesee,
1.
willdothewmk.erM the sbunurt isnotintrndedmoflered fm sale(Sec )061. BusNas
and Prefesrimu Codc: The Combatant's Licence Law docs tut apply in an owner of
oro cmpind s.pmvi mp teachimn.vm hu nwimw Mmesclforfm Went hu
owncmDloyecs.providedthauuchimprovemrnuveno imendedmatteredfmsale. If.
OCC. GROUP
RFS. NITS
TOT L
however. the building orimprevemem is nld widOnone yev ofcompinion, da wner-
builder will have the burden of paving Nat he did rot buiM m improve fm purpose of
-
QTY' _PLUMBING PERMIT - �. FEE
PLO OZONE
APN
sale.l.
❑ I. as nwnerafNeprepetry.ameaclusivelyconbactinp wiNlittnud conaanorsu
mruwn Ne project (Sec. 7(144, Business and Professions Code:) The Co.,
License law duet not apply m on owner of propcm who builds o improves Hereon. erW
PERMIT ISSUANCE
who conbamsforwch polecuwiN acanbananxl licenced puns. to the Canna ,
License Law.
ALTER - DRAIN i VENT - WATER (EA)
FEE SUMMARY
❑ 1 m exempt under Sec. , B i P C for this mann
BACK FLOW PROTECT. DEVICE
OUTMD=S
SANITARY Y N
RECEIPT.
Owner Dabe
DRAINS- FLOOR ROOF. AREA. GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y_N
�,❑ I hembv affrm that l haveaanifcam f,..t to self -imam, or a oenifacabe ofRECEIPT
Workers Campensuion Wuranmaracenifed copy thereof(Ser. 3900, lab C.) which
covin all employee's under Nis Perot.
Policy a
,
pS,ppR.�p
PARK FEE Y N_
RECEIPT' 0
GAS - EA. SYSTEM -I INC. a OUTLETS
BUILDING DIVISION FEES
Commmy
GAS - EA SYSTEM -OVER a MA)
PIANCHECK FEE
❑ Cmffied copy is hereby fomiahed.
GREASFIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cmifiedcopy is fJcd with Ne city impecdon Nvision.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 20(47.
ENERGY FTE
(This smian need not N completed ifthe permit u farone hundred dollars ($100)
arina)
WATER HEATER W/VFNT/F.LECTR
I cerJfy, that in the Performance of the work for which this permit is issue, IshW
an Play my pence N env manner so as eco become shim in the Waken'
PAID
mprnmiomyawa of Califgm s,
WATER SYSTEM/IRFATING
Data Rettipte
Applicata— VV
p,f��P�� sore.
NOTICT APPLICANT; If. after nuking Jtis Certifcau (Exemption. You should
NEW RESIDFNf1AL PLASB. SQ. FT.
TOTAL:
became wb ,w is each pr ComPcrmaoon pmisiouof dLabor Code.you mum
(onhwith comply with each povisions m Nis pemdt slWl be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LESDING AGENCY
1 herby affirm Net them m • combuctiam lending a,., for the perfannwcc of
the were fee which this permit is inued (Sec. 3097. Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Nme
-
QTY. .. MECHANICAL PERMIT .:, FEE -
PLUMBING FEE
Lender'a Address
I «Nly that I have sad this application and erne Nat the above informed. is
came'. lagrce mcamply with all city and county ordinmces roti mulaws rclningn
PERMIT ISSUANCE t I
MECHANICAL FEE
CONSTRUCTION TAX
buildingmmwction. ondhereby auNoria rtpmenutiva o(Niscity m emerupon Ne
above-ra mioned pupeny for impend. purposes.
ALTER OR ADD TO MECH.
(Wer vMe n vve, indemnify and keep hamiless the Cit, of Cupertino apemen'
liabilitin.judgonew emu aid expenses which nay in my way accrue against mid Ciry
AIR HANDLING UNIT LTO 10.0100 CFM)
in consequence of the grmtin of this permit.
• 1 D ^n
•(
AIR HANDLING UNIT (OVER IU.000 CFM)wne
EXHAUST HOOD(WIDUC)
PAID _S I/)
'ign eor ApFuean omesetm Data
HEATING UNIT (TO 100,(00 BN)
HAZARDOUS MATERIALS DISCLOSURE
RccciDt a
HE\TING UNITLOVER 100.000i BTUI
O
Will the cappliant or future building accupam store or handle haardws material
as de Wed by the Cupmom Municipal Code. Chanter 9.12, and Ne Health and Safety,
VENTILATION FAN (SINGLE RESID)
Cole, Section 25532(a)".
❑ yes O No
ISSUANCE DATE
Will theapplicanmrfuturcbuilrbeg occupant use equipment or devicawhichemu
BOILER- COMP(3HP OR 100.000 BTU)
BOILER -COMP (OVER 100.0!10 BTU)
surmounts air communism as defined by the Bay Am Air Quality Mar agerrcnt
-Uisme'?
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yet ❑ No
I have read the haardous maurials regmnmcros under CMpur 6.95 of the'-
4
Celifmmia 1leahh A: Safetv Code. Semiom 25505. 25533 and 2553x. I undmund dm
if des nm ounemly have a that it is my nuance
cu sm at t mustthe of a
occummr at rl¢ rcyuiremenm .hick mus be inn pion m issuance of o Cenifabe of
-- -
Occupurcy.
ISSUED BY: �--•V
Owner orumhoved a gam Dam
1 �/
OFFICE