24882 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL DING-F,LF.urRICAL PERMI'1'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEN'PIFICA]'ION 24882
BUILDINGADDRESS 06 � �� N SANT"1'ARYNO. AppLIGTION SUBMITTAL DATE
AI////YY LOT 0�
OWNyRS B PHONE: C( A 'OR'S AMG: LIC NO: V
J` N N/C CONTROLN
ARCHO2CT/ENGIN JiR: LIC NO: ADDRESS ❑ O
Cppp'A$� PE:
'1� v \l QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB OFSC� ON
M=Z Ihereby affirm that l am licenseduaderprovisions cf Chapter9(commencing with `BD /
+I 100 Sermon]IJ(I()of Division}of the Business and Professions Code,and my license is in PANELS � � .�
CU� full(onion!attest. Is
FZw License Class LiaN UPT02MAMPS
m Q y Dam Contractor 201-1000 AMPS
F
on
z ARCHITECTS DF-CLARATION OVER IOW AMPS SQ.FT.FLOOR AREA §/SQ.IT.
Z O
O'I.sn❑ I understand my plans shall la, N
used as public recos.
—
F vt [B SIGNS ELECTRICAL
Licenx)Pn+fessional
OWNER-BUILDER D TION SPECIAL CIRCUIT/MISC. II N
da�Oy O I hereby a[fim+that an exempt from the the ConComvanor's License Law Baltic I U
W3LLy following reason,(Section]031.5.Business and Professions Code:Any city or county TEMP.METER OR FILE INST.
ca
which rryuims a permit to construct,abet,improve,demolish,or regain any sw<tum DATE
cd prim ms ms ismance,also requires the applicant for such pernn to filcasigneJ statement POWER DEVICES Ip /J
W ed0.G O that he is licensed parsuant tome provisions of the Contm ons LicenseLaw(Chapter
o.xePe 9(commencing with Section 9000)of Division 3 of the Business and Professiont Code) SWIMMING POOL ELECTRIC fe VALUA
Amy or be is
exempt hcmfromand the basis exemption. llnlof
< Section 31.5byanyapplicant for aPrmitsubjects the opplicatortoacivilpenatyof OflLBTS-SWITCHES-FIXTURES
52nenrreban vehundred lars( '
1L
�O O�
❑ I.asownerofthcpopny,ormyemplnyceswithwagenaulheirsolecompensmiun, NEW RESIDENr1ALELECSQ.FI.
STORIES TYPECONSTRUCTION
will do the work.ond the stracmre isnot intended oroffertA for sale(Sm 9614,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
property,whobuildsor improves tormar,and whodocs such work M1imxlforthrough his
own employees,providedthm such improvemcntsam not imendedoroffcred forsale.If, OCC.GROUP RES.UNITS
however,the building or imp r..mum is sold within one ycwmf completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
solei.
❑ I,as owner ofthe FOpeny,am exclusively contracting with licensed monetarist. QTY' PLUMBING PERMIT FEE :[:::::FLOOD ZONE APN
constrict the pmlma(Sm.7044,Business and Professions Code:)The Contractor's
License Law docs not apply roan ownerofpropeny whobuilds orimproves thereon.and PERMIT ISSUANCE
who contracts forsuch projects with o comoremfs)licensed punuam[othe Contracmr's ALTER License Law. (EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B its P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE PEES
SANITARY YN
Owner DateDRAINS-PLOOR.ROOP,AREA,COND. RECEIPrJ#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that occni0cale of wnxmin self-tare,ora cenlGcom of FIXTURES-PER TRAP RECEIPTN
Workers'Compensation Insurance ora certified copy JareoffSm.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-Its.SYSTEM.I INC.4 OUTLETS RECEI N
Policy BUILDINC% TVIIION FEES
Company GAS-G.SYSTEM OVER 4(Eq)
❑ Cenifred copy is hereby famished. PL.ANCHECK
Cl Cenilied copy is fled wish line city inspection division. GREASFANDUSTRL WASTE INTERCEPT OR
GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This xctiuoneed on,he completed ifthe pemrit is foram hundred dollars 1$100) SEWER-SANITARY-STORM FA.200FT. ENERGY IEE
or max.)
I cenify that in the performance of the work for which this .it is issued,I shall WATER HEATER W/VENT/ELGCTR
not employ any pawn in any manner so as to become subject 10 the WorkersPAID
Compensatotiawsof Celifomiu. Date WATER SYSTEMOREATING Date Receipt
0 z Applicant
NOTICETO APPLICANT,If.of"marking'hisCenifcam of Exemption,you should NEW RESIDEN9'IAL PLMB, SQ.FL
F (q lamomesubjecflm she Worker's Compensation pmvislons of the Labor Code,you must TAL
forthwith comply w in such provisions or[]its permit shall be deemed ms alms. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEF,
z 1 hereby affimr that mere is a construction lending agency for the performance of
U O the work for which this .it is issued(Sec.3097,Civ.C.) 'i'OTAL: ELECT'
Lender's Name
U Lender a Address QTY. MECHANICAL PERMIT FEE PLUM
V 1 cenify shat I have read oris application and state that the above information is
comma. l agree aro comply with all city and county ordinances and stme laws minting to PERMIT ISSUANCE M HA 1.FET?
F (� building construction,and hereby authmize representatives of this city to enter upon the
U z above-mentioned property for impection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION T
(We)since to.save,indemnify and keep harmless the City of Cupertino against
liabili[ies,judgments,mil andexN swhixhmayinanywny accrue against said City AIRIIANDLINGUND(TOIt1,OWCFM)
quc a BuRZung f s omit.
�pt AIR HANDLING UNIT(OVER 10.(1110 CFM)
,gnature al'AppJ�Onv�i/OT'SA<a Do. EXHAUST HOOD(W/DUCT)
�� PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I110,000 BTU) Date RmeiptN
Will[hc applicant o,future building cumpaim snore or handle M1vallous material
as defined by the Cupcnino Municipal Cash,Chapter 9.12,and the Health.0 Safe, HEATING UNIT(OVER 100,000 BI U) TOTAL:
Cale,Section 25532(a)l
13 Yea 0N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUAN EDA
Will she aOulantnrfuwrtbuilnod by uhe Ba use equipment Quality
Management ? p 10 0
�,Jamenu-nabus air cumaminunts as defined by he Bay Uma Air QunlitY Management BOILER-COMP OVER 100,000 BTU) U+ W V
DiatnnY (
❑Yea CI NO NEWRESIDENTIALMECH. SQ.FL ® 1993/ I have read he havadms andenals requirements ands,Chapter 6.95 of the YMN'xg
if theouil building
s SafcCade,Stations23505,25533 and25534. Thyro rail thin r 111 INQ
ifcupain of the req not mentacurrently which
muthave a Ise m,prit itor my responsibility bf a Ce ific,n the r `u
0....st of me requirements which must be me prior to issuance of a Certificate of coV +i N
ossapaney.
Owner or authunand agent Date TOTAL: ISSUED BY:
OFFICE