24464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-N.LIX I'RICAL PLRMITNO.
APPLICATION/PERMIT PLUMBING-MEC IIANICA1. 24464
BUILDING DIVISION BUILDING PROJECTI DEN"I']F'ICATION
BUILDING ADDRESS:
1 /]-/s, }y-k��k�� SANITARY NO, APPLICATION SUBMITTAL DATE
2-�JV`� `-ir `"r I / •Sr1E UNIT# LOT It
' PHONE: CV�tION/AM�0FV4I8
1/70
7:F
N/C ` aCONTL#TROL##O M5IV'
AkA1ICT/CNGI;FFN LIC NO: ADDtI5• Liij cv Z —'
CONTACT: PITONL:
QTY. F.LIiCFRIC PERMIT PEE BUILDING PIiRM1T'INFO
BI.DTi ECf L ECH
PERMIT ISSUANCE- � L�FTt
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DP5CRIPTION
Oy Iherebyeffirtn that lam licensed underpmvisinrxm(Chuptcr9(cnmmencingwith
V�00 cation]000)of Division Sof the Business and P m
fess'oTTCme mylimmxisin _ PANELS
2
fall force and eff S� V IJPT'0201)ANIPS 1 It
F7,µ1 License Class 1 Lic.# ✓
yQL Date Cnnlmaum_%. r 201-101X1 AMPS _
15- AkC011'Ii[TS DECLARATION - �Sg.FP kiiA I
OZyO I understand my plans shall be,used as public records, SIGN ELIfflECTRICAL
AMPS AIS E IT IS
�yF-41 SPECIALCIRCUTAI. I� �] P � I T E
Q �� Lic,nsW Profesxiorml `V e V
aoeeQ OW I..exempt
DECLARATION SPECIAL CIRCUIT/MISE.
XOyonI_ '1 hereby affirm that I am ncmpt from the Cosions Ca License law for the .
W 3�y following rtnsom(Section 7031.5.flusmn.. Profession Code:Any city or county TEMP.MITER OR POLE INST.
�zSyg which requires.nmort ,ronanio, lmr,improve,demolish,or mp.ir.ny structure E
n its isn ,alsore,res the applicant f-mch pmor1.Bleu xignedsmminant POWER DEVICES
suace
�O tbm be is licensed pursuant to❑m pfnvisiansuf the Contractors License law(Chepmr
0(commencing with Section 7000)of Division 3 ofthe Business and Profauxions Code) SWIMMING POOL ELECTRIC VALIDATION
µ"j❑y
or h731.5bexempuhemfromtanti f the basisfor
sidjen,mimaminn.Anylpamaonof rilf W0__OUTLETS-SWITCHES-FIXTURES O
>
Section]03 L5 by any epplicnm fora pcm+it subjuts the applicam tmacivil penalty of \
•S mAmorc than five hundred dollars($500).
N m EII.mowneroftheprmpeny,ormyemploymswithwagesniheirsolecompenulion, NEW RGSIDFNTIAL ELF.CTR _SQ.FT. STORIES TYPECONSTRUCTION
yam will do the work,and theswcture is not intended nr offered for sale(Sm.]Bt4,Business
and Pone wions Cede:The Cmarartm s Licenw law does not apply to an owner of
pmpeny,who builds or improves thereon,and who does such work himselfor through his
OCC.GROUP RES.UNITS
employees ping or improvement
mentinvld wit menet dntend omplecrcd fivirsulaihe.w.Ir, +
huwevewillhav l the uimpmprovin ishathwithinone year or improve
for purpose of TO
huilAcr will have the burden of proving that he did not buil)or improve for purpose of
le.),
❑ I,us owner ofthe prnmeny,umexelusivelycummning with licensul conmactorsm QI'Y, PLUMBING PERM ff FEE. FLOODZONE APK
construct the project(Sec.71144,Business and Professions Cede:)The Contractor's 1 PI°IiMI'T ISSUANCE
Licensc Taw Jaen nm apply m m owner o(mropery who builds or improves thereon,vnJ
wboconimcmforsuchpmjectswiibaconlmcter(s)licensed purstantorbe Cnmmctore ALTER VENT I..w. WATER IRA) FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for this reason OMIDE FEES
BACK PlO W PROTECT.DEVICE
SANITARY Y N
Owner Date Rf:aamf#
•
WORKMAN COMPDRAINS-F1.00R,ROOF,ARTA,CONCOMPENSATION DECLARM'ION SCI{OOh TA% YN
❑ I hereby affirm that l have a certificate inconstant toaelf-insure,a amairicateof .RECEIPT'#
IBXTlJRl3-PER TRAP
Workers'Cnmpensationlasummarank:nified copy therm!(Sec.3tl1X1,LoM1 C.)which !' PARK FEF. Y N
rs all em loyee'e under tblx+coni,; RN.IVISI #
P 1 GAS-VA.SYSTEM-1 INC.40UTLETS I'oliay q BUILDING DIVISION PEGS
Company GAS-E.A.SYSTEM-OV E0.4(EA) PLANCHECK FEE
❑ C,nifioncopyisherebyfumished.
❑ CenifiW copy is filed whit the city inspection division. GRPASUs INDUSTIU.WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOIISFEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forme hundmddollars(SIMI SEWER-SANITARY-STORM FA.200FT. ENERGY HE
or taxa.)
I certify that in the performance ofthe work for which this Permit is issued,l shall WATER I ViAl ER W/VENT/EIAiCIR
not employ any person in any manner so as to become subject to the Workers' PAID
Contpcnxwion Uawsofcoiforra. Dain WATI!R SYSI'EM/IREATING Uma Reana If
O z Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW R I!SIDENTIAL PLhIB. SQ.M. TOTAL:
V7 become subject to the Worker's Cnmpcnavtion pmviadonsefthe LmborCWa,minast BUILDING FEE
•`�� ; forthwith comply with such provisions nr this permit shall be daemon revoked.
1 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE O
z Ihereby aft that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sm.3097,Civ.C.) =�� ELECTRIC PEE
Lender's Name PLUMBING FEE
F Lenders Address QTY. MECHANICAL PERMIT FFP. r
U - I certify that I have read this application and state that the above information is MEC.I{pNICAL FEF.
corren.Ingrceto comply with all city and umumy oMinancee and state lows relatingm PERMIT ISSUANCE.
building conswetiun,and hereby nuthnrizu rcprcsenmtives ohhie city memmrmpon the - CONSTRUCTIONTAX
U z move-mentioned to, fordnpectam Palo s. ALTERORADDTOMECE.
(We)o to ve.indemnify and om less Ne City of Cupertino ageimst
liahilinea,jud an .costs and expenses whim y in any way accrueagadnxt said City AIR I IANDLING UNIT(TO 10,0!1(1 CFM)
onxquen o he granting of Nix panni
AIR BANDLING UNIT(OVER Ilf"CFM)
, gmaturemfAl plicamVCmntmetor Data RXHAUST 000D(W/DUCII
PAID
IIAZARDO 'MATERIALSDISCLOSURE - IIIiA'I'ING UNIT(T0100,IN1OBTU) Data Receipt#
Will the applicam or fair,,building occupant smrc or handle hmnrdous mmmrad
mdeinW by The Cimarron Municipal Code,Chapter 9.12.and lire IIm1h and Safety I[EATING UNIT(OV ER 100,0110 BI'U) TO'T'AL:
Cod.,Section 25532(a)]
❑Yes ❑No VENTILATION FAN(SIN(SINGLEkIS1U) e"b6d 12,10
.Will the applicant m future bud Wingmuupanmsecqu!pmem ordavicawhichemif
BOILER-COMP(3HP OR IOg00d BTU) ISSUANCE AT•
• haaaNmma air contaminants n defined by the Bey Arra Air QualityManagementct? BOILER-COMP(OVER 100.000 BTU) AID
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have mad the hazardous materials requirements under Chapter fi 95 of the NOV 199
Culifnmialicullh&SafetyCale,Secfions25505,2,55J3amd25534. IunJcrsNtanddat V
ifrhe bnilAing J«s not curremly hnv,mm�unt,that it is my responxibilitymnrnify the - ,
t mecupum of the rcgoirnnems wlJch must be mw prior to Iseuunen of a CmlOwm of cl I y ur UUri(All J
Occupancy. - ���'r/�J�/��/�
Ownernrauthm!uAagem Drum ISSUED B)� g J
OFFICE