24466 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBU11,D1 G-EIAIC,I'RBC.L PERMIT NO, A
APPLICATION/PERMIT PLUMBING-MECHANICAL. 1
BUILDING DIVISION BUILDING,PROJECT IDENTIFICATION
BUILDING ADDRESS
y/� /�/ {� L SANITARY NO, APPPLIL'HONISSUU/BMI TIAL DATE
V(0 O oaKT PL,J! LOTa i lr I l'
OWNS SIIL.ILIC NO
1 jibs` �� CON'1'A`r R'S NA�:r� N/C CON'IAOLa
ARCHI TiCfENGINF,ER: LIC NO: ADD Rok"
SS: f_
691'S w d
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECII
PERMITISSUANCE ❑ ❑ ❑
LICENSED CON'I'RACfOR:S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCi
OKZ InBOBofumision 3 offh Bu inss and Pr ifesio Ch Cole,
and
is in /f
YJ OO Senioforce and of Division J of the Business and Professions Cock,acro my license is in PANELSfull (/
FyF�j-yylf--
License
Clndeffacl.
FLW License Class Lic.p UPT02U0 AMT'S
yQy Dam Co.'.'., 201-1000 AMPS
1—y ofARCHITECTS OfCLARA'I'IUN OVER 1000 AMPS
SQ.FT.FLOOR AREA E/SQ.FT.
ZOm— luaburacndntyplans'snal no used as publicrccarJe.
pL F W
I SIGNS ELECTRICAL
QY7J Licensed Professional
�Q OWNER BUILDER OF LARAI'ION SPECIAL CIRCUIT/MISC.
IL 1 hereby affirm that I um exempt from the Contractors License law for the
m3aon following reao
sn(Section]031.5,Business and Professions Code:Any city or county TEMP.MOM OR POLE INST.
1❑❑'�O; which tequircs a .it to commas ane,,improve,demolish.or repair any svumom
prior to it issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES
Cm K Q that he is licensed pursuant to the provisions of the Contractors License law(Chapter
1�0X 9(commencing with Section7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIO�
X.
actual lie ixexempl therefrom and lite basis for theadcgal exemption.Anyvwlaunnor
I..:ZY Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES {Al v
=p not mart than five handfed dollars(5500). NEW RESIDEN'IIALELEC'UtSQ.FT STORIES TYPE CONSTRUCTION
CHp ❑ 1,nsowneroftheptnitcrty.ormyemployeeswithwagcsaathcirsolecompensvtlon,
a3e= will Johne workandthearvcture isnrn imm�JCJ proffered forwle lSec9044,Business
and Professions Code:The Commences License law Jou not appy to an owner of
property who builds or i mproves thereon,and who does such work himself or through his
own employees.provided thin such lmprovemensaenol intendedoroRercd flotsam.If. OCC. RIS.UNITS
however,the buildingor improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the human of proving that he did not build or improve for purpose of
sale')' PLUMBING PERMIT FEC
❑ Los owneroftne property,srnexclusively contracting with licensed aommdpreto QTY. 1TOOD%ONE APN
consumer the project(Sat.7044,Business and Professions Code:)The Contractor's
Liceme Law does not apply manawnerofpropcity who builds Or improves thcomin,and PERMIT'ISSUANCE
wnocnnvacts factum pmjects with uconnnatons)licensed pursuant o the Contracmrs
License Law. ALTER'-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempn under Sce. ,B&PC for this reason BACK MOW PROTECT.DEVICEO SIDE FEES
ARY YN
Owner Data DRAINS-FLOOR.ROOF.AREA,COND. RECEIPI'a
WORKMAN COMPENSATION DECLARATION SC .TAX Y N
❑ Inereny affirm thatllhuvcacenlf cam of cmusent lit xelLinsurc,oro cenifcale of PIX'1'11Rf5-I'I.R TRAP RECF.IPTa
Workers'Compensation Insurance lir a certified copy lhercof(Sce.38tH).Lab C.)which PARK FEE Y N
cors all emly derthi{perhElI GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'p
covers
Isdicya �n•� r001— n BUILDING DIVISION FEES
Compoyyy GAS-EA.SYSTEM-OVER 4(EA) PLANCI TECK FEE
i;Wnifed copy is hereby fumjnh s].
❑ Ccnifed copy is fleA with the city inspection divixion, GREASEANDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE VI'EXEMPTION FROM WORKERS' GREASETRAP SOILSFEM
COMPENSATION INSURANCE
Thissectinn remnant becontplmcd iflia,mnit Nfnranc hundre(fdollsrs($100) SEWER-SANITARY-STORM EA.2WFT. IiNERGY FEE
to..)
I moify that in the performance of the walk for which this Permit is issued,Is hall WATER HEATER W/VEN'DELECIR
mnpiny any parson m :my manner wt as m become subject to the Workers PAID
Compenutionlawsof Culifumia. Date WAI ER SYS]INGREATING Data Rcceipta
O z Applicant
z 0 NO UCE TO APPLICANT:If,after making this Cenifcate of Exemption,you should NEW RESIDENTIAL PIN B. SQ.FT. TOTAL:
;-t r/7 ;Object n the Worker's Com,meninn pmvlslmus of the Labor Code,you most
la' ? Forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCT ION LENDING AGENCY SEISMIC FEE
z I hereby affnn that them is a construction[coding agency for the performance of
U O the work for which this pemhit is issued(Sec.309].Civ.CJ TOTAL: ELECTRIC FEE
Leader's Name PLUMBING PEI?
Under Address QTY. MECHANICAL PERMIT FETE
0 U I certify that I have read this application and state that the above information is MECHANICAL FEE
L1] correct.l agree nm comply w hh all city and county oninances and state laws relating to PERMIT ISSUANCE
f" N boiliingennWantiun,and nerebyuuthoom reprewrillaive,idlins city tocaterupon the CONS'1'RULTION TA%
abo m mentioned pot for inspection purposes. ALTER OR ADD TO MECH.
t (We)agree to save.jndemmI and keep Ie phe City of Cupcnino again.
Ilabilllles,j gmcnu.cows and expenseswhich mu u y wayuccrueagnm sad CBy AIR HANDLING UNIT(TO I0.000 CFM)
i0 can nsx of the grumill is permit. //
Z HANDLING ANOLING UNIT(OVER 10.000 CFM)
mg of
Si uturcp V10"
p licant/ "ba or p ¢ EXIIAUST IIOOD(W/DUCT') PAID
HA'J.ARDOUS MATERIALS DISCLOSURIi HEATING UNIT(TO 100.000 BTU) Dae Rcceipta
Will the, phatur or future building occupanl.ore or handle havaJous material HEATING UNII'(OVER 100,00b BTU) T
as Jefned by the Cupertino Municipal Cede,Chapter 9.12,and Ne Health and Safety
Cede,Section 25532m)q VENTILATION FAN(SINGLE RCSID)
❑Yes ❑No
ISSUANCE.DATE
Will thcapplicant or furore Wildingeccupcot usecqulpmcmmdeviceswhichcm[t B011.17R-COMP(3HP OR 101,000 BTU)
hazardous air conmminancs as(formed by the Bay Area Air Quality Management BOILER-COMP(OVER 100,01 BTU) qq pp ff��fI,,
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the lima dous materials requirements under Chapter 6.95 of the 4V0 V 1 kgs
California l lenith&Sofahy Cade.Smtioma 25505,25533 and 25534, l understand that n
if Ins building domes not curtently M1uve a tenant,that it is my srymsibility w notify tnc (s t
poapum o[hoe Gemm�ts which mm't h mat Dior(o fimotmcc o[n Cc terra 9 6�T �f talc• "
12cupatucY.
Owner a tut orired v lit am TOTAL: ISSUED BY: \
OFFICE /'