24830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I(�
CITY OF CUPERTINO BUILD ING-",hUTRICAL PERMITNO. 2 ^ H 3 O
APPLICATION/PERMIT PLUMBING-MECHANICAL LLf
BUILDING DIVISION BUILDING PROJECT IDENTIFICAT]ON UILD)ING A4DRIi.S�'S:// T� T SANITARY NO. APPLICATION SUBMTITAh UATI
/ /� • / I vA/�' `�"�� At UNIT# LOT of
OWNERS NAME: ,�ff pp PHONE:99'� _ TRACfOR'SNAME: LIC NO:
11, D. NI �/N Z.J�J Z. a5 N/C CONTROL#
�CHYECT/ENGINEER: LIC NO: ADDRESS: ❑
CONI'ACI': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE / � � ❑
LICENSED CONTRACT'OR'S DECLARATION
cAPPLIANCES-RESIDENTIAL
CCZ Ihrcbyafmthat lam "OBiILSCRMjION
' J
4100 Section? O)of Division 3 ofthe Businessand Pmfcsslom Code.and mylicense is in PANELS ,1/� �\
K V F full force and off., r `
F"L 4I License Class Lic.0 UP TO 204 AMPS
yah Dae Commaor 201-1000 AMPS
Z OFtoZ ARCHITECTS DF,CLARAI ION OVER IOOU AMPS SQ.IT.FLOOR AREA $/SQ.FI'.
O Z—a 1 understand my plans shall he used as public records.
P L!="I SIGNS ELECTRICAL
6YE,0 Licemed Professional
2 .w< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KLO p.
W U L hereby affirm that I an exempt from the Contractor's License Law(,,,,he
ti m
F"4 of
fulloveingreasoa(Section 7031.5,Business and or Professions Code:Any city county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any srucmne
prior m its issuance.olso refract the applicant for suchpe.iuo fileasignedswmmed POWER DEVICES
,=<0 that he is licensed pursuant o the provisions ofthe Contractor's Lic<nse taw(Chepmr
a o� 9(conmcneing with Section 7")of Division Jofthe llusmessand Professions Code) SWIMMING POOL ELECTRIC VALUATION
ku.m or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
FZQ Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of UTLETS-SWITCHES-FIXTURES
c¢ nm re than five hundred dollen($500).
o, L+suwncrofthepropenpormy employees with wages as tbeiroe compensation, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPF;CONSTRUCI'I@
'' L the work,ond thestralumeisnot imendedmoffcred outside(Son,7044,Busioms
not[Incursions Crxle:The Contractor's License Law does not apply Ian owner of
propcny who builds or improves Mer<on,and who does such work himself or through his
own employees,providedthat such impmvementxare not imendedoraffereA forsale.IL OCC.GROUP RES.UNITS
howeveq the have
the
burden
improvement is sold within one year or improve for the owner-
ble.), ill have the harden of proving that M1c did not build or improve for purpose of
tole.(.
❑ Las de project pmpeny,a.Business
oil nractlngwith CLicen no Contractor's
QTY. PLUMBING PERMIT FEE FLWDLONE qpN
mnvwd the project Nov.70x4,Business and Professions Crde:)The Commctor's
whonseco trawdmcs not apoyto with arturnmepeny whosed para improves thercoContra and PERMIT ISSUANCE
who Laws for such projects with acnmranor(s)licensed pursuom m MCCommmmrs
License Law. ALTER-DRAIN&VENT-WATER(IA) FEESUMMARY
❑ I aen exempt underSec. ,B&P C for Mit mnsun BACK FLOW PROTECT.DEVICE OUTSIDEtF.ES
SANITARY 1' N
#Own[I Dam DRAINS-FLOOR.ROOF.AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ Il ICOyalinnlhmlhoveaecracemcofcon thend to f(iec.390r LabC.)which
FIXTURES-PER TRAP RECEIPT#
:=::Compensainn ins this poracertifedenpythereof(Sac.JNW.Lab C.)which ytK FEE Y N
coven allcmployMs under this pcmtit GAS-EA.SYSTEM-1 INC.4 OUTLETS e RECEIPTp
Policy# C"T BUILDING DIVISION FEES
CompanyGAS-EA.SYSTEM-OVER
11Ccnifedcopy ishcrchyfumishcJ. R4(IeA)—j .ANCHECK PEE
❑ CenifieJ copy is flet with the city inspection division' GREASEONDUSTRL WAS'T'E INTERCEPTOR ING FEF,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectima necJnot becmmpined ifthe permit is furore hundred dollam($I W) SEWER-SANITARY-STORM EA.XIUFT.
fe".) ENERGY FEE
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER WNENT/ELECB
nd employ any pawn in any manner w as to become subject to the Workers PAID
Applicant
Z Compenamio Lavoi.f CalifomF.
ia. Dale WATER SYSM/TREATING Dam Rceeiptp
Q
Z O NOTICE TO APPLICANT:I',atternmking this Corti ficam of Exemption,you should NEW REST DEN 1'IAL PLM. SQ.P, TOTAL:
ybecame subject to the Worker's Compensmiun provisions of the(redo Code.you must
foMwith comply with such provisions tar this permit shall h deemed revoked.
� �_ BUILDING FF.F.
ZP0 CONSTRUCTION LENDING AGENCY SHISMIC FEE
Z Ihereby affmt thmlhefeis.conatrwflim lending agency for the performance of
U O the work for which this psmit is issued(Sec.3W7,Co.C.) TOTAL: ELECTRIC FEE
Lender's Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
Da c 1 certify Mat 1 have read this application and state that the above information is
F" Pn meet.l agree to comply with all city and county ordinances and state laws relatingrr PERMIT ISSUANCE MECHANICAL FEE
_ building construction.and hereby authorize representatives ofthis city to enter upon the
U •Z above-memimned property for inspection purposes. ALTERORADDTOMECII. CONSTRUCTION TAX
(We)agree to save.indemnif and keep handless the City of Cupeninr against
liabiliti ,jud 'ena,arstsande meswhichmayi..ywayaarvcagainslsaid City AIR HANDLING UNIT CIO IO,0WCFM)
in ar quer (this permit.
AIR HANDLING UNIT(OVER IO,000 CNM)
Sgnomm rF anVContmcom d Dae EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]T(TO IW.OW BTU) Date Rcceip#
Will the applicant me future building occupant Wore or handle hazardous mmerial
as defined by the Cupertino Municipal CWe,Chapter 9.12,and the Health and Safety I HEATING UNIT(OVER IWdXO BTU) TOTAL:
Code.Section 25532(a)?
❑Yes 0 N VENTILATION PAN(SINGLE RESID)
Will theacontaminatewes defineg by the bay
AreaAenmuality sanagement
ROLLER-COMP QHP OR 100,100 BTU) ISSUANCE DATE
hmallous air contaminants a defined by the Hny Area Air Quality Management BOILER (OVER 104,000 BTU) p
Ditmm? W
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. /T
L
ve real Mc moat us materials rcyuiremm�ks under Chapter 6.95 of the ��q� ti p
lleulth&Safety Cade.Sections25505,25533 and 25534. 1 understand tha illing does not currently M1avc a mnant,Ma it is my responsibility m ntifthef the refuirements which must W met prior to issuance of a Certificate of authorize
agent Date w�`/^p,•rL•:,/IAr�ly
TOTAL: ISSUED BP
OFFICE