24972 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILVENG InLEcrRI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING..MECHANICAL. n /I [�� n
BUILDING DIVISION BUILDINGPROJEC"T IDF.MI249 L'IFICATION
BUILDING ADDRESS: ((jj{� 11 rn1 SANTI'ARYNO. APPLICATION SU13MITI'At.DATE
"TAQM V 1S;� UNIT# LOT# Gt_V_k—a.3
OWNERS NAME,:' _ PHONE: CONTRA R'S � v NO:
�# ' e 1 N/C CONTROLN
ARCHI'IECT/FSGINVa LIC NO: ADDRESS: �^- _ / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELEC9PLUMB MECII
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
cxz I hereby affirm that l am licensed under provlsimasof Chapter9(maimencingwith LOB DESCRIPTION
{DOO Section 70000 of Division 3 of the Business and Professions Code.and my license is in PANELS vep��
Fy WP� full force and effect. 1
NZ, License Class Lica UPTO2W AMPS
Qd Date Contractor 201-1000 AMPS
1'-,z
—ARCHITECTS DECLARATION OVER I(XIOAMPS I'. ' OR AIEN S/SQ.17.
LC Z—Ct I monistical or,plane shall he uud as public rcands. \\VV''
L..,,n w SIGNS ELECTRICAL n n
i,j Licensed Professional n ; /i f- 1U T E R
yQ OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
W O:0 1 hereby affirrin that I am exempt front the Contractor's License city
for the
413ci¢ which requirsa permit tocO31S,Businese andve,de iolih.orreaiAny city nruclumcounty '1'IiMP.METER OR PoLLINST.
�' J wM1ich rcyuires a permit to construct,alter,improve,Acmolish,lir repair any swnurt
yru3a5 prior to its issuance.alsoomares Ne applicant(orsuch permit to file a signed statement POWER DEVICES
K that he is licensed pursuant to the pmvismm of the Commeators License Use(Chapter
i$o�' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
w=m or that he is exempt and the basis for the alleged exemption.Any violation of OUTLETS SWIJ'CHES.FIXTURES
FZa Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not mart than five hundred dollars($50X).
5 aNEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
C � ❑ I,mownerofthepropeny,ormyemploymswithwagesestheirsolecomp ration.
will do the work,and the structure is not intended material Result(Sm.INFL,Basilicas
and Profccvions Crdv:Lbe Contractor's License Law docs not apply to an owner of
Property wbobuildsorinmpowesthercon,andwhodurs such work himselfor Nnsugh his
employees.provided Nat such improvcmemanrenot intendcdoroffercdfmsale.IL OCC.GROUP RIS.UNITS
however.the buildinger improvement is sold within one yearofcompletion,theovener- TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose of
sola.). QTY. PLUMBING PERMIT FEE
❑ Los owner of Ne pmpeny,em exduxivelyamvuning with licenced convectors to FLOOD ZONE ANN
remover the pmject(Sec.7W,Business and Profeanions Core:)The Contractors __
License Lawdocanot apply town ownerofmaperty who builds or improves thcrtoa.vnd PERMIT ISSUANCE
whomntmets Torsion projects with a rontrommurs)licensed puuant
rsto the Cantracwrs ALTER-DRAIN&VENT-WATEREA
License Low.
( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&1'C for Nis nano" DO I:SIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AR PA.COND. RECEIPTb
®
covers WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm thatlhaveacraificvte of content toself-insure,oracenificvm of INTURES-PER TRAP RECFIPTb
Workara Compeasnion Insurance lir a certified copy thereof(Scc.9glNl,Lnb CJ which PARK FEE Y N
ors all employee's under this permit. GAS-EA.SYSMEM-1 INC.4 OUTLETS RECEIPTb
Policy b BUILDING DI VISION IBES
Com any GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Ccrrifed copy is hereby famished.
❑ 'enilic l copy iv triad with the city inspection division. GREASUNDUSq'RC WASTE INTERCEPTOR GRADING hili
CERTHTCATE OF EXEMPUON FROM WORKERS' GREASE TRAP SOILS REE
COMPENSATION INSURANCE
(This section need not be completed ifthc permit is for one hundred dollars(3100) SI2WER-SANITARY-STORM EA.20017. ENERGY FEE
or leas.)
Iccoy in Ilia p in my maaf ser,so res torwhichl,ispemtito ire Workers'
WATER HE:A'1 ER W/VENI'pi1.ECTR
not empty any l- persen in any manner so m to become subject to the Workers' PAID
Compenmtion Laws of Cali(omia. Date WATER SYSTIiM/TREATING Data Rettiptb
O z Applicant
z0 NOTICE TO APPLICANT 1LaBer making this Certificate of Exemption,you should NEW RESIDENT'LAt.PLMB. SQ.FT. TOTAL:
ry becnmesubjmtm the Worker's Compensation proviumex.fthe Lahor Code,you most
tZ forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING IEE
❑.1SEISMIC Rif:
Q CONSTRUCTION LENDING AGENCY
P. I hereby vfOrm that there is v construction lending agency for the performance of
U O Ne work for which this permit is issued(Sm.3097,:D z Co.CJ 'f ELECTRIC FIiI?
Leaders Name PLUMBING 103E
C U" F lander.Address QTY. MECHANICAL PI7RMIT FEE
U I terrify that I have read this application and state that the above information is MECHANICAL FEE
acorrect. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
DO building consvuction.unit hereby audience representatives ofthlseity to enter upon the CONS'DRUM iONTAX
U z aMwcmcnnumedpmPcny for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save.indemnify and keep hanNess Ne City of Cupertino against
livbiliticsjudgments.costsand expenses whichnay in any way accree against said City AIR HANDLING UNIT CFO IBM CFM)
const
fine✓`n=in=of thio permu� AIR HANDLING UNIT(OVER 00.O00 CFM)
Signature of Applistem/Comiser.,_/w klhr5\ Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0001 BTU) Data Recall,0
Wit I the applicant lir future building occupant store or handle hazardous material
as deli tied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I]BATING ON I'I'(OVER I(m,00H)BTU) TOTAL:
Code,Section 8532(ay! VENTILATION FAN(SINGLE RESID)
❑Yaw ❑No
ISSUANCE DATE
Will the applicant lir futurcbuildingaecupant use equipmentordevices which emit BOILER-COMP(3HP OR 100.00(t BTU) 11��
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) p
District?
❑Yes ❑No NEW RESIDENTIAL M[C11. SQ.FT.
1 have mad the hveardous materials requirements under Chapter 6.95 of the �Q�141993
Cabounin I Icalth&Safety Code,Sections 255(15,25533 and 25534. 1 understand that
inhe building does not currently have a tenant.that it is my responsibility to a nify the Gr11 IIVU
occupant of the reyuircments which must be met prior to issuance of v Certificate of p�� G yi
Occupancy. VID Is
Owner lir aulhorizcd agent Dote 'TOTAL: ISSUIiU BY�V_