24463 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IMAL IIING-RL-C'I'R1 AI- 'PERMIT NO.
APPLICATION/PERMIT
PLUMBING CI IDENTICAL 24463
BUILDING DIVISION BUILDING PRodEC'I'IDENTIFICATION
BUILDING ADDRRESS. SANITARY NO. APPLICATIONSUBMDTALDATE
VY I J -2- l I /7I �. UNIT# LOTq 'I— 2.-Ica
OW '�NgMO I / PHONE: COMTRgCfO���: N/C - CONTROL#
ARCHITF-C)'//ENGINEER 1.1 NO: ADORIE/!!J�:�� l / ❑
CONTACT:�. PHONE: / 9'' BUILDING PERMIT INFO
S QTY. ELECTRIC PERMIT FEE/ G�I PERMIT ISSUANCE BLDG ELECT
P B
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RE•SIDENTIAL OB DESCRIPTION
Oa:Z Ihere0I.I'mthml amfthe edunderprovieionsn(Chapte,and
(commencing se with ,
ts100 S«tion7000)of Division Sof the Businnsend Professiorm Code,end mylicenu is in PANELS
W full nse<san5es<.r,r�ecs. ! /t/ a
. S.
FZW Liana Cl Lic.M 0 // UP TO 200 AMPS
yQN Dam Commccor 101-1000 AMPS
Z O ti Z ARCHITECTS DEC =ATI SQ.FT.FLOOR AREA ;/$Q.Pf.
OVEN 1000AMY5 ,q L E D I N
O Z,W I understand my plans shall be uud m public records.
EF4SIGNS ELECTRICAL p /I
CG Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. {Y/I 1 C
XC1 iU 1 hereby affirm that I am exempt from the Commctola License Lew for the Y V v G
Fa%ONQ following....(S.on 703 1.5,Business and Professions Code:Any city or county TEMP.MITER OR 1401-11 INST. ^
y J which requires a permit m canswct.eller,improve,demolish,or repair any structure
O�
KW7 prior to am issuance,alsorcquims the applicant for such pact to file a signed statement POWER DEVICES
w9<0 G that he is licensed Financial o the provisions of the Convectors License Law(Chapter -
a. o� 9(commcvcing with Section 7000)of Dividon 3ofthe Business end Profession,Cods) SWIMMING POOL ELECTRIC VALUATIONW
r^y othat heisexempt Nerefmmemlthe basis for the alleged exemption.Anyvusm.not OUTLETS SWITCHES-FI%TURCS
�ZG Section 7031.5 by any applicant for.pe.it,.bj.h theapplieenno a civ"inthyof
mare than Eve hundred dollars($500). NEW RESIDENTIAL ELEC IR _SQ.FT.
C�2
net❑ I,esowncrofNeprUperry,ormyemployeswith wagnutheirsolecompewmian, STORIES TYPE CONSTRUCTION
y3o0 will do the work,end thestmcmm isnot imendedoroffemd(orate(See.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimproves#command whod«ssuch work himselfor through his
OCC GROUP NES.UNITS
ownempl�y�s,ProvidW that such improvememeurenot imendMoroffercd fmtele.
If,
however.the building or improvement is sold within one yearafcompletion,the owner- TOT L:
builder will have the burden of proving that he did not build or improve for purpose of
,ale.). QTY. PLUMBING PERMIT' FEE FLOOD ZONE APN
❑ I,er the pr eject pr c. ny,7041 amexdusis an c Professions C de:) he Corecmmo
License the proj«t(gee. ono Business and Pw(nsiw,Code:)The Cammmare —,
-t-
License Law does not apply towownerofpropeny who builds mImproves Nerew,and It PERMIT ISSUANCE
who contra ds forsuch projects white conueccor(s)licensed pursue to the Connector's
License Law. ALTER-DRAIN&VFiNT-WATER(EA) FEE SUMMARY
❑ 1 amexempt under Sec. ,B&PC for this Mason BACK PLOW PROTECT,DEVICE SANITARY OUTSIDE DE F N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECFIPT#
• WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certificate otconsenno self-insure,or a certificate ofFI%TURPS-PER'TRAP RECEIPT#
Workers'Compensation Insurance or acenifiW copy thereof(Sec.3800,Lab CJwhich PARK FEE - Y_N
overs all employee's under this Permit. GAS-Ek SYSTEM-I INC.4 OUT LET'S RECEIPT X
Policy p BUILDING DIVISION FEES
Company CL OAS-PA.SYST'13MAVTA 4 WA) PLANCHECK CEP.
❑ Ceniriedcopyisberehyfumished.
gCenified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERSOREASETRAP - SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed iffle permit is forune hundul dollars(51fid) SEW17R-SANITARY-STORM PA.2WFL ENERGY FEE
less)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER IMATL'R W/VENT/ELECPR
O ,2 not employ any rj�} m any,fn IFI sn �Irecdt fnhj«t to the Workers' PAID
CompensationL alifar l mm /L/ Lam_ WATER SYST hETREA9'ING pace Receipt#
Z NOTICETOLICAN ,after making this Ceniliwm of Exemption,you should NI:W RP.SIDEM'IAI-?LMB. SQ.FT. kOTAL
{-i V) become suM1jem tothe Wo es Carinate tion pro,iinm of the Labor Cade,yonromc
�i , forthwith comply with Hoch provisions or this permit mall be deemed mvnkeJ. BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE
zIhereby affirm tharthere is a consWnion lending agency for the performance of
f, O he work for which this Formic is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's NomePLUMBUJG FEELender's Address QTY. MECHANICAL PERMIT FEE
V I certify that 1 have read this application and&rate that the above information is
correct Iegrce mcomply with all city and coumy oNinencn wJamte laws Medingm PERMIT ISSUANCE w MECHANICAL HE
GO building construction,and hereby authorim repre&enmtive,of thiscity menterupon the
U 7 nbove-men'o property for inspection purposes. ALTER OR ADD TO MEC14. CONSTRUCTION TAX
rte- (We a to save.
Linde ify11,1A
l hazmlas,the City of Cupertino.,air,,a"jud ents,cosis spaichmayinwyway accrue ugeinq aaiJ City AIR HANDLING UNIT(TO 10,000 CFM)
en f Ne grand r of Nit.
I q AIR HANDLING UNIT(OVER 10,000 CFM)
Signorine of Appiic o vector Dem(/ IIXIIAUST BOLD(W/DUCT) t PAID
o RDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO 100,000 BTU) Data R«ci,,N
Will the applicant or future building«cope,nom or handle harandous mnem.)
u defined bythe Caused..Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER UX)JW BTU) TOTA
Code,Section 25331(e)?
❑Yes VE GTILA'I'ION FAN(SINGLE RFSID)
No
Will Ne applicant or future building«roper use eqm
uipmenr devices which emit
BOILER-COMP(3HP OR INT0011 BTU) ISSUANC
haxien ous air contaminants as defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER 100,000 BM
District?
❑Yes 0 No NEW RESIDENTIAL MECIi. SQ.FT.
1 have read No hmerdous materials requirements under Chapter 6.95 of the
if the
building
Ileahh&Safety Code,Sections 25505,25533 and 25534, Intro understand that
iftheiedo th sumownmoctimend ave tenwWhet normyamenceibility to notify Ne NOV 1 2
«roper o(Ne uiremcnm Lich 7 R me prior m issuance of a Certificate of
Occupancy.
Occupan authored,goat One10% ISSLOY BY:' _
OFFICE