24467 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CTPY OF CUPERTINO JJU ILDI G-ELECTRI CAL PERMI9'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2446 A ^
BUILDING DIVISION PR(iF,(;r BEN"TIFICATION L Li b
BUILDING ADDRESS: /� .. �`xx�) SANITARY NO. AI'PLICA9'ION SSUBMI'IIT�A�L DATE
S1 Y r0V� TPrL LOT It
OWNERS NAME: PHLS;7—ONE
` CONTRACTOR`'S NAME: LIC NO. Y
J - n N/C CONI ROLN
ARCHITECT/ENG EER: LIC NO: ADDRESS: /
2,' fi tG w � laAkd, I
CONTACT: PHONE:: (TTY. ELECTRIC PERMIT FEF, BUILDING PERMIT INFO
d.UG '5TPLUMB MLCH
PERMIT ISSUANCE 5 c
LICENSED CONTRACT OR'S DECIARATION APPLIANCES-RESIDENPIAh JOB DESCRIPTION
pyL I hereby affirm that l um licensed under pmvisionx m Chapter 9(commencing wish
ts100_ fallSection en11c Dlvidon3nfthe Nosiness and Prufeuiom Code,and mylicensc is in UPT02
FttWFF fullnse Classelfem.
ajW
License Class G {FyI `L ASS $ UP T02W AMPS
y6d Date ILL/v 9 Cocavc n. a ., rY
201-Iqq AMPS
I"yZ ARCIIITF,C'1'S DECLARATION T 1. �Rr
ZOm— I understand my plans shall 6e used as public tremors. OVER 1(00 AMPS 19L\V,
OG—❑
I-mf'; SIGNS ELECTRICAL
q hiccn¢d 1'rofcxeianul {F
yyd'G OWNER-BUILDERcleanpfrom he Contra,,
SPfiC1Af.CIRCUIT/MISC. • L.
W')W'p, I hereby reason.(Section
that 1 am emtnpt from the Ciesimo,Co License law for thet-
tA�OvFi which ingarre,aermit to 7031.5.crasamt,alle,iendve,deiom Co de:Anycity orcourt,cture TEMP.MEfIiR OR POLE INS'It T'C
—y j which mqurtesa permitmrnnama,stmt,rm
crunch
moanh,orrepair eel xtrvem:n G
S�YC) that be islicensed
.rsu 7(t to the
provisions
s ofonuchpermiuo file ase La statement POWER DEVICES
u°W(0.K thatmisncing with S pursuant ro")id'ivisinf the Ce Basins and
Isce6nw(Chaptcr.
a KCLL 9(cnmmencing with Section 9000)of Divixinn3of the Rosiness end HofesaimnaCode) SWIMMING POOL ELECTRIC VALUATIOM
W—y or that he is exempt therefnnnead the Maus for the alleged exemption.Any violation of QU'1'LET$-SWITCIIES-
F Z QSection 7031.5 by any applicant for a permit subjects the applicant m a civil FIXTURES
not mntnthre five hundreddollars(SSW). pF penalty mf
u m ❑ 1,mowneratfthepmp Tty.ormyemplm ecswithwa mastheiraolccmn NEW RESIDENTIAL F.LECIit SQ.FT.
y g pcmation, STORIES TYPECONSTRUCTION
will do the work,and the simulate is not Intended mrmffered forsale(See,7(N,1,Easiness
unit Profession Cade:The Contractors Ucenx Use does not apply to an owner of
property who builds Or impuwc,therenn,and who Lines Such work hawelrm through his
own employces,pmvided thateuch improvements menotimendedmoffcmd fonele.If, OCC.GROUP RES.UNITS
however,the building 7(r improvement is sold within one yeand<vmplction,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I.2S owner Ofthe pmpeny,amexclmivelycOmneting with licensed contractors o QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(See 7044,RUSHICSS and Professions Code)The Contractor's
I�icen¢L:wdess not apply to an ownerofproperly who builds or improves themm,and PERMIT ISSUANCE
whoornmel,for,cach prvJen.vwith.,oraso (0 licensed par,uunuothe Contractors ALTER-DRAIN&VENT'-WATER EA
License Use. I ) FEE SUMMARY
❑ I m7(csempt under Sec. ,B&I'C far this¢anon BACK FLOW PROTECT.DEVICE OUTSIDE Flips
SANITARY YN
Owner Date RECEIPT 0
•
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCIIOOLTA% YN
❑Workers
Co petent.Imer ance.,i(mateied ers dicers f(Sceum,or acttd(rnich RECEIPT
Wmrkeri Cam FIXTURES-PER TRAP
pensationlnsurancemattnifieJ gimpy tM1crdrf(Sec.JBW,Lab C.)which PARK FEE YN
n all cmplo t Icnhis I mit. _ GAS EA.SYSTEM-I INC.401f1'Lh'fS RECEIPT'M
Policye'0-�O U 7 "L
Policy N„/_0 BUILDING DIVISION TEES
Company a-N nerd.
Cjj'Fnified copy is M1emby fumiaheJ. GAS-FA.SYSTEM"OVER 6(PA) PLANCHECK FIE
❑ Ccnifinl copy is tiled wltM1 tM1c city inxpcninn divicine GREASMNDUSTRL WASTE INTERCEPTOR
GRADING FF.Ii
CER'H1�ICATEOFEXEMPITONFROM WORKERS' GRIiASLTRAP SOILS LEE
COMPENSATION INSURANCE
PT his section need not he completed iftbe fernit is fomes hundred dollars($100) SEWER-SANITARY-STORM EA.200FP. ENERGY FEE
or less.)
lcerify that in the penumuce ofthe work for which this .it is mired.[,list[ WATER HEATER W/VENfYELECTR
not employ any person in any m as m become subject to the Workers' PAN
,� Compensation Law,of California. Data so WATER SYSTF,MITREATING pec RcmiptN
Applicant
Q O NOTIC17 TO APPLICANT:fl:abet making this Comficmr of Estma,somyou should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
Fy become subject in the Worker's Compensation provisions,ofthe Labs,Code,you must
rx 5 forthwith comply with such provisions or this permit shall be derated revoked. BUILDING FEE �►
y
CON Sri SEISMIC FEE
Z Ihereby affirm that here is a construction lending agency for the performance of [LECIRIC FEE
(� O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL:
Lenders Name
O F Leaders Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
U I ttnify that I have real this application and state that the above aParmation is
correct. I agree to comply with all city and county radiance,and suite laws relating to PERMIT ISSUANCE MECHANICAL FEE
rn building construction.and hereby authmrac representatives Ofthis city lmenlcrupmn the
V Z abtve-memionedpcopery for inspection putpOee. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree m,eve,indemnify end keep hunches the City of Cupertino against
liabiliti ,' Jgmems.coxu endexpenus whle may in any way accrue agdmt said City AIR HANDLING UNIT(TO 10,000 CFM)
inecc of the goat sof iS pant
A
AIR HANDLING UNIT(OVER 10,001)CFM)
Si arc ol;Applir t/ omn ter Mae EXHAUSTH000(WNUC)
U PAID
IALARDOU$MATERIALS DISCLOSURE HEATING UNIT(TO 1 W,d(p BTU) Dae Receipt N
Wil I the applicant or future building cerupunt store or handle baznrdmux material
as dc(nal by the Cupertino MunlclPal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25532(a)P
❑Yes No VENTILATION FAN(SINGLE RISK)
Will tEeepplicnmrfuwrthuildinga cpanome qipmemnrdevices whichemiBOILER-COMP(3HP OR L00,000J00 BTL)
ISSUANCE DATE
hazardous air comimucti to as defined by the Buy Area Air Uaality Management BOILER-COMP(OVER I100.00)BTU)
Districts ❑Yes ❑No 1y A 9 j)
NRW RF_SIDEN"1IAL MECH. SQ.FT.
1 have rend the ha,ardous maluml.s requirements under Chapter 695 Of the Ilio
California Health&Safety Code.Sections 25505,25533 andW 'V
255
.lundcomend that Ja
iV 12
f the building docs not currently have a tenant,that it is my responsibility to notify the J
Occupant f he requirements wIt muss met p7( to issuance of a rifie a of 61/�
oeaapt // L b if 'VI
IYs/
Ow6cr is,uudu2-du 7(t D.ur TOTAL: ISSUED BY: V
OFFICE