24553 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUIL ING r,.KURT I RICAL PERMIT NO.
APPLICATION/PERMIT PLUMB -MECHANICAL 24553
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMTITAL DATE
ZOO O Z 'uI 4/o /Al UNIT# LOT# 1�C
OW ERS NAME: PHONE: CONTRACTOR'SNAME:,� LIC NO: N/C CON ROL#
/
fry= /__VV// /]
ARJ=_ /CI'ENGINEA: O�\� _ LIC NO: ADDRESS: ❑ /�1 /c7,,2
CONTACT: ✓ 'AT'�•P-/H•"O�NIE:_ BUILDINGPERMIT INFO
�� ���oj _ �/ QTY. ELECTRIC PERMIT FEE
'�vV/s I y "r�� I/'-"Jf� B ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB CRIPTION
Qwz Ihereby affirm that l am licensed underpowisionsofChapter9(commencingwith
�a 00 full ion]00d ofect. on 3 of the Business and Professions Code,and my license is in PANELS A �_,. / / T\� r
V402 Scott land effect.
Nf S !'Zyo
F,ZW License Class Lie. UP TO 20F AMPS
yD Data Contractor 201-IBM AMPS
z OyuARCHITECTS DECLARAI ION OVER IWO AMPS SQ.FT.FLOOR AREA E/SQ.IT.
CZ-0 I understand my plans shall be used as public records.
F� W SIGNS ELECTRICAL 1O O O
,a Licensed Professional
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
00.[0'
- aso1 hereby affirm that I em exempt Four
the Contractors License Law for the
a p� following ren.(Section 7031.5,Business and Profession Code:Any thy m emsety TEMP.METER OR POLE INST.
f 1 rte which requires a permit m consumer,alter,improve,demolish,m repair any structure
a� priorroitsissunnce,alsorequiresheepplicamforsuchpmi0ofileesigndetaremenn POWER DEVICES / /SIaN4
q G that he is licensed pursuant to the provisions of the Contr'actor's License Law(Chapter 971/ l
axolr. 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
F❑y or that he is exempnherefromand the Wsis for the alleged exemption.Any violation of /?
X a
Sciatica 7031.5 by any applicant for u permit subjects the app]icanno a civil penalty of OUTLETS-SWITCHES-FIXTURES -6:2 q'-70 OOYI
^k I VV
a 22 not morethen rofthe roe rtyl,ormSSW). NEW RESIDENTIALP.LEM FT.
❑do the
work, re
orrofwialfar mei(sole compensation, —SQ. STORIES TYPE CONSTRUCTION
y will dothewons andthe Me Contractors
notintendede Law does,
an Business
and Professions Cotle:'fhe Cantmmors License Lew does not apply lr an owner of r
progeny wyees,pmlds orimproveuchereon,and ermar essuch work Mmfferedihrrnghhis
ownemthe
ged Nat such rventmis sold msarcmt inroolfco planed fiarthe owner,e.If, OCC.GROUP RES.UNITS
however,ill have
the human o vement is sold awithin one build or improve
a for
purpose
o-
builderwill have rhe harden of proving that he did not build or improve for purpose of
sulgo.-
T as QTY. PLUMBING PERMIT FEE FLOODZONE APN
ownerMtte propSrc. W, Business mad Professions
withlicensed Contractor's
avant the project(Sec.9(kW,Business and Professions Cmac)The Contractor's
ease Lawdoesnutapply torn ownerofproperty whobuildsorimproves thereon,tied PERMIT ISSUANCE x
hocuntracts for such projects with a conomm((sticensedpursuant to the Contractor's ALTER DRAIN FEE SUMMARY
License Law. (EA)
❑ 1 ern exempt under gee. ,B&P C for this reasonUTSIDE FEES
BACK FI.OW PROTECT.DEVICE
SANITARY Y N
Owner Data DRAINS FLOOR, AREACOND. RECEIPT#
WORKMAN COMPENSATION - , , , .DECLARATION SCHOOL TAX Y N
❑ Thereby affirm thntl haves cenificete of cansemmself-imar,ma.atifica¢rf TEXTURES-PER TRAP RECEIPT#
Worket%Cotnpensation Insurance or acetified copy thereof(Sec.38W,Lab C.)which PARK FEE Y N
covers all employee's under this perrit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policyq BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(Fit) ( PLANCHECKFEE ��J- p♦
S
[2 Certified copy is hereby famished
❑ Cer ifiedeopy is Pled with the city inspection division. GREASHANDUSTRL WASTE INTERC GRADING FEE
9.5'.00
CERTIFICATEPE COMPENSATION
EXEMPTIONFROMWORKERS' GREASE TRAP SOILS FEE .nO
COMPENSATION INSURANCE
J
his section raccoon be completed ifthepermit is furore hundred it.]].(SIM) SEWER SANITARY-STORM EA.200FT.
or les 01 ENERGY FEE
I costly that in the perforoance oftha work ferwhieh this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' / PAID/.Z/4Z f2
Z Compensation Laws of Califomia. Date WATER SYSTEM/1'REATING x Date #
Applicant
Z 2 NOTICE TO APPLICANT:ILufler making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. BQ,FT, IL qqL.
V) become subject to the Worker's Compensation provisions of the Labor Code,you must
a forthwith comply with such provisions or this permit shall be deemed revoked. BUILDIN a—
Q CONSTRUCTION LENDING AGENCY SOS MI /p' O
1 hereby of]!.that there is a construction lending agency for the performance of FEE
U Q the work for which this permit is issued(Sec.309],Civ.C.) T CTR 3 3
IJy rr Lender's Name
U PLUMBI EE 12
Lenders Address QTY. MECHANICAL PERMIT FEE
U 1 terrify that I have read this application and state that the above information is I A151
acorrect l agree to comply withal]city and county ordinances and state laws relating to PERMIT ISSUANCE MEC ICALFEE
.,r building construction,and hereby milimiaerepresentioncerf this city to enter upon the STRUCTIONT
U 7 aMve-me tinned property for inspection purposes. ALTER OR ADD TO MECH.
�7 (Wc)agree to save,indemnify and keep harmless the City of Cupertino against
liabi]Ities,judgmems,cos dexpensesyehto maymanywnyaccrueegapa1 said City AIR HANDLING UNIT(TO IO,fI00 CFM7
are onsequence of th40
s trot. (,/ / /
? AIR HANDLING UNIT(OVER 10,0011 CFM)
Signal of Applaeopci aractor Data EXHAUST HOOD(W/DUCT)
pq
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.00)BTU) Dote Receipt#
Will the applicant or future building occupant stare or handle hazmdcas material HEATING UNIT(OVER IOO,WU BTU) T
as de-tied by the Cupertino Municipal Circle,Chapter 9.12,and rhe Health and Safety
Code.Section 25532(a)9
11 Yea C1 No VENTILATION FAN(SINGLE REBID)
Will the applicant or future building occupant use equipment ordevicee which emit
BOILER-COMP(SHP OR IW,W BTU) ISSUAN DATE
a¢mdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPOVER]00,000 BTU
DistrlcB ( )
❑Yea ❑No NEW RESIDENTIAL MECH. SQ,FT. PAID
1 have read the hazardous materials mummerents under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that (I#�#�
if the building does not currently have a tenant,that it is my responsibility to notify the AP
ccupant of the requirements which must he met prior m issuance of a Certificate of
Occupancy. ^
Owneror°uthorized agent Dare A ISSUED BY:
OFFICE