24529 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B N4- ,LECTRICAT PERMITNO.
APPLICATION/PERMIT
PLUMBING 24529
O RUILDINf.DIVISION BUILDING VROpF,TT IDENTIFICATION
BUILDING ADDRESS SANITARY SANITARY NO, APPLICATION SUBMITTAL
-
Z o •o S UNI'Ta LOT#
CO ACI' S � �rO r {AXa N/C CONTROLp
R HIIECT/E:NCINEER: LIC NO: A11&1 /g e ^ _ rMS
CONTACT: PHONE: QTY.
VW Y'���ql-I,p'^,i► DUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG IiLECT PLUMB MECH
PERMIT ISSUANCE, l ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz I hereby affirm that l am licensed underpmvisionsofaapter9(commencing with J BDESCRIPTION
IY00 Section 7000)of Division 3 of Ne Business and Professions Code,and my license is in PANELS G. �.a �
FFjyvU� full force and effect, r�(� '
fZW License Class Lit.# UP TO 200 AMPS
F<hDDate Cerrito r 201-1000 AMPS
, , ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FI'.FLOOR AREA $/SQ.17.
07-0 ]understand on,plansshell beused as publicrecords.
P N F en SIGNS ELECTRICAL
<Y7� Licensed Professional
W=M< OWNER-BUILDER DECLARATION SPECIAL CIRCUHYMISC.
KOyU 1 hereby affirtm that I am exempt from the Commences Licxme Law for the
W 3 a y following reason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLIS INST.
O; which requires a Permit to construct,alter,improve,demolish,or repair any structure
KWQS n
prioo its issuance,also minims the applicant for such permit file a signed stam
teent POWER DEVICES
aap0 that he is licensed pursuant o the pravtsmns of the Contractors License Law(Chapter
�' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
m0 VALDATION
=m or that he is exempt herefrom and the basis for the alleged exemption.Any violmionofOUTLETS-SWITCtIES-FlXTURES �•
FZ_Q Section 7031.5 byany applicant fora permit mbjects the upplicanuonCivil pcnalry of
no,mom Nan five hundred dollars($SILO).
C ca ❑ I,uowncrofthe Proluny,ormyemPlOyaswithwagesutheirsolecompensation, ;NEWESIDENTIAL f:LECIR SQ.FT. STORIES TYPE CONS"]RUCTION
a3?2 wil]do the work,md theswcmre Isnot intended oroffered for sale(Sec.7044,Business
and Professlom Code:The Conbecior's License Law does not apply to an owner of
property whabnildxor improves thereon,and whodoessueh work hitiselfonhmugh his
own employees.provided that such improvementxam not intendedoro(find forsale.If, OCC GROUP RBS.UNITS
however,the building or improvement is sold within one year ofcompletion.Ne owner-
builder will have the burden of proving that he did not build or improve for purpose ofsada).❑ Luownerofthepropmy,amexclusively<ontmctingwiNlicenas:dcommnmsto QTY. PLUh18ING PERMIT FEE FLOOD ZONE APN
conswet the project(Sec.7014,Business and Profssions Code:)The Commaor'sLicense Lawdacx not apply man owneroBm,hmy who builds crimproves therean,and ISSUANCE
who contracts forauch pr..jens with a evisitations)licensed pursuunuo the Commemr s
Liccmc Law. At.TER-DRAIN dt VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE TEES
SANITARY YN
Owner Dare DRAINS-FLUOR.R REA.COND. RECEIP`F#
WORKMAN COMPENSATION DECLARATION S LTA( y_N
❑ Thereby.ffirm that l have a evnificace ofamsenno self-insure,or a certificate of Fl%TURFS-PER TRA J I RL'CEIPI'p
Workers'Compensation Insurance or acemBed copy thercof(See.3800,Lab Cd which I' R cF Y N
covers all employee's undef this permit. GAS-EASYSE -1 4 1 RECEIPT pPolicy N
Company BUILDING DIVISION FRES
❑ Certified co hereby famished. GAS-EA.SYSTEM-OVER 4(EA) P A HEC FEE
yr is
❑ Cenificd copy is filed wiN Ne city inspection Division' GREASFJINDUSTRL WA. CEP]' GRADING sE
CERTIFICATE OF EKEHsDON FROM WORKERS' GREASE TRAP SOILS'
COMPENSATION INSURANCE
(This section need not be completed tithe permit is for one hundred dollars($]00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orless.)
I cemlY that in the performance of the work for which this omt ix issued,I shall WATER HEATER W/VEN'I/CLECTR
not employ any pars, is any manner sr as ton a Jen to the Workersots ' PAID
mpemmin w fCalifis Om WATER SYSTEM/URGTING Date Receiptp
z NOTICE APPLICANT:If. Bear makmgth¢C<roficate o4rd ption,YOushould NEWRESIDENTIALPLMB. SQ.FF. TOTAL:
Fcome subject to the Workers Compensation provisions of Nor Code,you must
a forthwith comply wi N such Provisions or this permit shall be d invoked. BU TIDING FEF.
CONSTRUCTION LENDING AGENCSEISMIC FEE
Imo- z I hereby affmt lhauhere is a construction lending agencforhe performance of
V O the work for which this Permit is issued(Sec.3099,Civ.C.) 'TOTAL: ELECTRIC PER
Lenders Name
p U Lenders Addrtss QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LT-I I<atifY Nat I have read this application and me in.. ove armormhon is
correct. Iagree Ineempty with all city and county ordinances aate laws rtlatlngw PERMIT ISSUANCE MECHANICALFEE
building conzwction,and hereby mahome represcnwbves of tcity"enter upoo the
V z uhnve-mentioned prnN:rty for inspection purposesACItiR OR ADD T'U MGCfI. CONSTRUCTION'TAX
(We)agree car save,inticmniry Vkcephcss the CCupmino againstIiabllitie;judgments,mats'emexpenayeugamu'LISCi AIR HANDLING UNIT(TO 10,000 CFM)
in tithe g
AIR HANDLING UNIT(OVER 1Q000 CFM)
Stag sure of Applicant/Commmor / re EXHAUST HOOD(W/DUCT) PAID
HA9.ARUWS MATERTAI.S DISCLOSUHINTING UNIT(TO 1011,I)Op BTU) DateWill the applicant or future buildingoccupant store or haamrdous materialas defined by the Cupertino Municipal Code,Chapter 9.12,anHealth and Safety HEATING UNIT(OVER 100,000 BTU) AL
Code,Section 25532(a)9
❑Yes ❑NoVENTILATION FAN(SINGLE RESID) 16
Willdis'plieam Or fnumbuildingeccupant useequipment ordevices which emit BOILER-COMP DHP OR 100,00 BTU) ISSUANCE DATE
halco:e an conterminous as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU fR�yy��
District? ) 1r A O D
❑Lbuilding
Yes ❑No NI7W RESIDENTIAL MECI I. SQ.17. DEC1 'I(]
read the hazardous materials requirements under Chapter fi95 of the ^ I�92
ealth A Sefcty GMe,Sections 25505,25533 and 25534. I understand Nat
g does not currently have a tenant,that it is my responsibility tonotify Ne
the reyuimmepuuanceoacnicate of rI I r L/I- LUrLv
Fl111ron ..ed agent Date
"TOTAL: ISSUED BY:
OFFICE v J_ _