24745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOP 11.111 G-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24745
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APIP�IACAIIONSUBMUTALDATF.
UNIT» LOT»
OWNERS NAME: PHONE: CONTR�1'OR'S NAME: LIC NO: N/C CONTROL»
e/5 I4,q/L7',,s As-55-517 t✓ //, sCan n hls�X27 7.JS
RCHITECI'/ENGINHER: LIC NO: ADDRESS:
r645' 1411"t 044k, &"A-- 9`L1 ❑
CONTACT': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ ;K
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIA1.
O=Z Ihereby affirm that l mon licensed under provisionmfChap..r9lemamencing with LOB DIiSCRIPf10N
�00 Section]fKKBaf Division 3 ofthe Business and Professions Cale,and my license is in PANELS
K V Bill lorcc amt cK"?6 ^ 7 Lam? 4 S^ 1 P
cuZW Licedse Class Lie.» L J
N¢y
Data Comrecmiultt/iefri If 10—IfT t4Ae 1 s
ZONy A CPIITF,CTS OECGRA'1'ION
OV I 1 P SQ.IT.FLOOR AREA E/SQ.FI'.
Fyr-a lardersmWrny pbma anal he usW as Pahfiar«aryls. " s I L y
Y 2 j Licensed Professional t 'i•
=W< OWNER-BUILDHR DECLARATIONP CIRCUIT P C.f
OiO 1 berchy affda but I ant exempt from the Con nica is I.iccnse Law fur Ihp _
W'TWy following reason.(Section]031.5,Business add Professions Code:Any city or roum�_ TEMP.ME OR POLE INS'1'.
1,_"a O Q which requires operant m construct,alter,improve,demolish,or repair any suet...
} prior to itslsmance,also requires the atiltforsuch Permit file a signdxutemeet POWER DEVICES
4 Thal be is licensed to the provisions of the Cmnrara,"License Law Chapter
W—00 SWIMMING POOL ELECTRIC VALUATION
aXo4 9(commencing with Section 1000)of Division 3 ofthe Business and Professions Curb)
W=ti or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCH[5-Fl%TLRES
�Z¢ Section 11131.5 by any applicant for a permit subjects the applicant to a civil penalty of
ptSp
not more Than five hundred dollars(5500). NEW RFSIDIiNTIALIiLECIR _SQ.FT. 'OR1ES '1'YPECONSTRUCI'ION
K F-o ❑ 1,asowneroOM1epropeny.ormycmploy«swiN wvges axtheirsolecompensation,
y3°_° will donc�wons andc: he Contisnotimendeseawdoes of apply 11 k4,Rosiness '
and erny whions Calc The Con.acain.License Law Acus not apply to an owner of
own errywyees,pdsoded deasschimpr and who does such work himselfurthrough his
employees,provided lhatsucM1 improvcmentsma not inmrMedoruffemdf.rsale.If. OCC GROUP RIS.UNIT'S
however.the building or improvement is sold within one yearofeampled.n,the owner- TOTAL:
hudde,will have the b,,den of paving tont ha did not build m improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APE
❑ I,asuwnerofthepropeny.amexclusivelycontmctingwithli«nsdcod.act.,u
mswet the project(See 1044.Business and Professions Code:)The Contractor's
License Low does nal apply to.mowner ofpropeny who builds.,improves thereon,and PERMIT ISSUANCE
whecontracu forsuch projecu with ae.mmctor(s)licensed punuumm the C.mractma
License Law. ALTER-IIRAIN&VENT-WAIFR(G) FEE SUMMARY
❑ I um exempt under Sea B&P C for this reason
BACK FLOW PROTECT'.DEVICE OUTSIDE FEES
SANITARY Y N
\ Owner Date p
DRAINS-FLOOR.ROOF,AREA,COND.
RECIiII'I'
�. WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that I have acciddicme ofc.nsent to self-insurt,aru certificate of FIXTURES-PI?R TRAP RECEIPT a
Wmkers'Campen.smion Insurance ora«nified copy lllc,«f(Scu.3500,Luh C.)which PARK FEB Y N
covers all cmplglys' t Ca. / GAS-EA.SYSTEM-1 INC. OUTLETS —RECEIPT#
/ Policy» sIb � BUILDING DIVISION FEES
Campaay—S1 tT' /��"V GAS-EA.SYSTEM-OVER4(F.A) PLANCHF,CKFE.E
❑ Certified copy is hereby famished.
)�Certified copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OP EXEMPDON FROM WORKERSGREASETRAP 5011.5 FEE
COMPENSA'JILN INSURANCE
(This section need not be completed ifthe Permit is for one hundred dollars($100) SEWER-SANITARY-STORM HA.200FT. ENERGY FEES
or less)
1,raify that in he perfomwnce.f,he oak for which this permit is issued,Ishill WATER HEATER W/VENT/F,LECTR
not employ my pers.n is any mann +as to beer a subject to the Weaken PAID
Compensation laws of Califomia. L*I11��� WATER SYSTEM(IRGTING Date R«eiptp
Z Applicant (/v
Z � NOTICE 10 APPLICANT:if.alle,makinglhis Cedifictecofli..omption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f'^ became subject to the Worker's Compensation provisions of the Labor Cade,you must p
> forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby offimi that them is o construction lending agency for the piummunce of
'z TOTAL: ELECTRIC ITE
U O the work for which this permit is issued(Spy 3(191,Civ.C.)
Lcndch Name- �� PLUMBING PEE
u-' 1<craj Addrc B QTY. MECHANICAL PERMIT FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE u-Q
correct l agree to comply with all city and county ordinances and state laws rclming to PERMIT ISSUANCE - —00
F-' building construction.and hereby authorize representudves ofthis city mentor upon the CONSTRUCTION TAX
V Z above-mentioned propvny for inspection purposes. ALTER OR ADD TO MECH.
(We)vgme m save.indemnify mal keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO ELM CFM)
in consequence of the grunting of this Permit.
AIR HANDLING UNIT(GVHR 10.000 CPM)
Signature of ApplicunUComractor Date EXHAUST HOOD(W/DUCr) .E
PAID�G�r43
HAZARDOUS MATERIALS DISCLOSURE I IEATING UNIT(TO 100,1100❑TU) I pp Date Receipt»
Will the applicant orfuture building«cusent store or handle havardous material TOTAL:
fIGTING UNIT(OVER 100.000 BT11)
as defined by the Cupertino Municipal Care,Chapter 9.12,and the Health and Safety
Code,Semi..2553200/ VENTILATION PAN(SINGLE?RFSID)
❑Yes ❑No
BOILER-COMP(3HPOR Igj.BTU) ISSUANCIi DATE.
Will lM1e applicum or future buildingrccupant useeyuipmem ordaices which emit `� W
�
lu%air contaminant as defined by the Bay Area Air Quality Management BOILER IOO,WOBTU)o, otl 41993
❑Yes ❑Na NEW RESIDENTIAL MECtI. SQ.FT.
/p� / i
1 have Ih ow'e Cull,/rquimntent under Chapter e.YS of the r Gln 1 Uy� O
Califomia�6f<(y CNc,Sections 25505,25533 and 253]4. 1 understand Nat Ur V V
if the bails g dms not currently have a tenant,that it is my responsibility to notify the V 1,
occupant of the requirements which must he met print to Issuance of a Cenifcute of
Occupancy. q'� .•y�// /1
Owner,,mith ired.gem Data TOTAL: 6 ' O L ISSUED BY:Me /Y/y70A1UCG•
OFFICE