24547 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOtl H.JING-hLhCTRI CAL PERMIT NO.
BUILDING DIVISION ' APPLICATION/PERMIT 1'I.UMIIING-MECHANICAL /� A ag
BUILDING PR(JEC'P IDE\I'IFICA'I'ION L 4 5 4
BUILDING ADD^RESTS:. �gyay-/��r/�{�y4�/� /�� SANITARY NO. APPLICATION SUBMITTAL DATE
OW ' SN ,►g • PHONE: R 'S NAME: # LIC NO: N/C CONTROL#
M1 •N, `yy7 (��� y ❑
• ABOUTECLENGINEF.R: LIC NO: D}y? ✓- _`MI 1
lV— � G ,
CONTACT: PHONE: BUILDING PERMIT INFO
Q'I'Y. IiLECTRIC PERMIT FEE
1]Lq(i, iLECT PLUMB MECII
PI?RMIT'ISSUANCP." 7115C(Ir ❑ ❑
LICENSED CONTRACTOR'SDnsoffaATION APPLIANCES-RESIDENTIAL �� �.I0B DESCjRIPI'IQtIv ^�y�
OCZ Ihcmby affirtm ENSEDlicensed CONTunder pmvisDECL R.ATh9(commencing with
00 Sectirn]WO)of Divisiun3of the Business and Pro(ecsinnz Code.and my license is in PANELS
WdE fall h,rmaw eff .
p¢-Zu1 1.iccn.c Clnss c —I Lic.# Cv3-710N UP TO 200 AMPS
Date 1-014 Contra".,
� 201-Io00AMPS - R�
w$ ARCHITECTS DECLARATION ImA OVER TAMPS mr'
O)OR rT� $/Sp.IT.
Q .0 SIGNS ELECTRICAL
Q Licensed Professional OWNER-BUILDRR DECLARATION SPECIAL CIRCUITIMISC. L'� u✓ _ ER
CCOaF 1 hereby ufrom that 1 um exempt from❑be Cnmructo's License Lew for the w •
Spm foll"wingreason,(Seoion]o31.5,Businessund Professions Cale:Any city or county '1'EMP.METER OR POLI:INST. DA
(.aa an.Q1 which requires a permit to construct.alter.Improve,demolish,in repair any structure
KpL of
prior it)its issuance,also te,mast the applicant for such permit o file a signed statement POWER DEVICES
p1 a_IZO that he is licensed pursuant to the provisions of the Comtndors License Law(Chapter
9(commencing w iib Section 7000)of Division 3 of the Business and Professions Code) SW IMM ING POOL ELECT RICVNII
W_so union he is exempnerc
hfm ruandthe basis for the alleged esemaJ
ption.Any violation of OUTLETS I V'_6
Y�Y Sectinn]031.5byanyapplicam for.,crmitaubjoetstheopplican w itsivilpeneltyaf
�TQ tmnretwnfvelhepro Jnllnrmyem). NEW RESIDENTIAL ELHM —SQ.R. s
415Cp oho n❑ Lthe%or ,andtestrucy,ormyemployceswithwod t usalei(Sec.cum,ensutie., S'fOR11S TYPLCONSTRUCTION
L will d"thewon,andthehe Coclsnot ttuimendese Laaf den. sale to an Business
and erty who
Cale:The Improves
demon, nd who law such
not apply to an owner of
pupeny whobuilJanrimprovexthereon,and whrdrnwch workNmselfonhrough his OCC.GROUP RES.UNIT'S
ranoemployees,p building
ori pr suchimprovementsore me
iear oudurnffercd forsale. r.
however,the building burden of ancon is hath a did
one build
of mprove for the owner
builder will have the harden of proving thin he did not bui1J or improve for purpose of
❑ I,as owneruftbepropmy,am exclusively conttazting with lianuJ contracrorare QTY. PLUMBING PERMIT FEE ROOD LONE APN
on.num he project(Sec.7144,Business and Professions Code-)3Le Contractors PERMIT ISSUANCE.
License Law deea oat apply to an owner at property who but IIs or improves themon,anJ
who counters forsuch projects with ucontractorp)licensed pursuant o the Contractor's ALTER EA
License Law. (' ) FEE SUMMARY
❑ 1 am exempt umJer Scc. ,B&P C far this mason BACK FLOW PROTECT,DEVICE
_ SANITARY Y N
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affimuhetlhaveacenifi<ate rfconsemmsclf-insure,orocmificme of RECEIPT#
Workers'Compensation lummanceo rse,rifW copy meonf(Sa.3800,Loh C.)which ITXTIIRES-PIiR TRAP PARK FEE Y N
vets 11111 emfyr�e�! tWs pen9u GAS-EA.SYSTEM-(INCA OUTLETS RECEIPT#
Po'cyp_ ' Y 7V 4 BUILDING DIVISION FEES
C pant' ' e Fo - GAS-EA.SYS'rBM-OVf:R4(F.A) PLANCILECK FEE
Certified copy is hereby furnished.
❑ .eriftedcopy in fled withthe city inspection division. GREASIVINDUSTRL WAS TE INTERCEPTOR GRADING FEE
CEIGIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
GliseeeionneeJ not be,completed ifthe permit is furore hundreedolhos($100) SHWER-SANITARY-S'1'ORM IiA.2WIT, ENERGY FEB
or tesh.)
I certify that inrhe performance of the work for which this permit is issued,Ishall WATER I II/TFR W/VEN1'/F.LECTR
.at employ any person in any manner so as to become subject to the Workers PAID
Com,ereaion Lawsof Celifomis. Date WATER SYSTEM/TREATING Date Receipt#
Z Ap,liano
NOTICE TO APPLICANT:IG.Rer mode this Cenificaoof Emun t TOTAL:
g pion,you should NEW RF.SIDIiNI'IAL PLMB. SQ.FI'. I
z IZI become subject..he Worker.Compensation pmvisio®ofthe Labor Gude,you most
-a ; forthwith comply with such previsions or this permit shall be deemed mvoked. BUILDING FEF.
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
.D z Ihereby affirmtat them is a construction lending agency for performance of
U 0 the work for which this permit is issued(Sec.3(19].Civ.C.) TOTAL: ELECTRIC FEE
V. Lender'.Name PLUMBING FEE
Lender. re
.nde .h - QTY. MIiCIIANICAI.PERMIT' PEE
U I certify that 1 have read this application and state that the above information is
�" 0. comet.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
1-' building construction,and hereby oahonu representatives ofthis city tremor upon the - CONSTRUCTION TAX
U Z above-mentioned properly for inspection purposes. ALT'ER OR ADD TO MECII.
(We)agree m save,indemnity and keep harmless the City of Cupeminn against
liabiliries,judgmend,c nand expensesw 'ch may many w.y.m.irsumm amid City ALR I IANDLING UNIT(TO I UAW CFM)
in onscyuenmo Ingo it.
AIR(IANDLING UNIT(OVER 10,(gll CPM)
�2
tgnat e f ppletm o tha l", to "HAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000,BTU) Date Receipt#
Wi11 the applicant or future building acepum store or handle hazardous material
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I]HATING ON]T(OVER 1(93,000 BTU) TOTAL
Calc,Section 25532(u)'1
❑Ycs ❑No VENTILATION FAN(SINGLE RESID)
BAILER-COM('(3HP OR W.WO BTU) ISSUANCE DATE
Will theapplicant nr future huildingoccupant mue,ei,man ordevices which unit (� '
hazardous air contaminants As refined by the Bay Area Air Quality Management BOILER-COMP OVER 100,800 BTU Ir
District? ( ) '
El yes 0 N NEW RESIDENTIAL MECH. SQ.FT. j�Tr.� �/k��
I have rend me buzardaus matmals requirements under Chapter 695 of the flJE` a92
Califomia Health&Safety Come,Sections 25505,M533 and 25534. 1 understand that CI�a VI- `�'��i
if the building docs not currently have a Wham,that it is my responsibility o notify the 1
mcapant of the mquirements which must be met print to issuance of o Ceniftcate of L�l'Cfl 111
Occupancy. man
Owner to madmdaed agent Dae TOTAL: ISSUED BY:�
OFFICE