24701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO I BOMBING-KLERI AL PERMITNO. O
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDIN s'DIVISION BUILDING PROJECI'IDENTIFICATION
BUI E.
-TIG ADDRESS: v a SANITARY NO. APPLICATIONSUBMITTALDAT
L 1
UNI'Ta LOT t --UAL
sAMOWN' NAME': P11 NE: CONTRACT'OR'S AME: LIC NO:
W
nit., - �y N/C CONTROL#
'H H EU1/FNGf1fGGGIN///EER: LIC NO: ADDRESS:
CONTACT': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BIAG LELT PLUMB MECH
PEIIMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Manz Ihereby affirm Nal l sm licensed underprovisionsmfChxpter9(commencing with
PIb Section 200o)of Division3of Ne Business roti Professions Code.and myliuveisin ##NETS1 .fir/
IY�_ full fame antl cffec1.— . ' Lia p,_r� 201UiP-I 0 AMPS �e ` arm 'Y,'
Fz se Clara '/`7r-'[i/S--^—
y= .m Ca rSDr yg/✓r py 201-111W AMPS
20 y RCIIITECI'S DE A ATIO SQ.En FLOGggR__-���pp��lpp E/SQ.FT.
cz pp I understand my plans shall be used ns public records. OVER IOW AMPS
Pooh - BIGNS ELECTRICAL 3140
g 51�! LicenuJ PrcPossionel
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT(MISC. [MOO J
A
iW0.�SdOL VVF 1 hereby affirm ihm I am exempt from the Camrenot's License Law for Ilia
u+3ON following reason(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INSE
C y which requires a permit to construct,altee improve,demolish,m repair any swcturep / Ik p
f ry prier to its issuance,aIs.repineslhe applicant for such permit I.fleesignecl memem POWER DEVICES 03
�V/ \VR
Q p that he is licensed pursuant m the proviaiom of the Contractors License law(Chapter
�,,.E 9(commencing with Session 7")a(Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALU.YI'WIS
ty c^y or that he70 eaemptny pplic and far.basisfonheallcgedcaemptian.Any violation of OUTLETS-SWITCHES-FIXTURES'
�Q not ore than veby vundredicmtrs($50rmit subjauthe applicant toecivil penalty of
O not more then five hundred dollars($500). NEWRESIDENTIALELECfR —SQ.FT.
❑ LmnwneroOheproperty,ormycmployees with wagwestheireolecomPanuflum, STORIES 'TYPE CONSTRUCTION
q will do the work,andtheswcture is not intended oroffered Beside(Sec.9044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work himself or through his
own empleyees,provided that such improvcmcrosmems imendedoroffcmd forsale,If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner. ,ro
builder will hove the burden of Lanvin,that he did am build m improve for purpose of
❑ Lnewncrofthepropeny.ran exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE F1,00D ZONE APN
construct the project(Sec.7044,Business and Profesions Cade:)The Contractor's PERMIT ISSUANCE
License Law does not apply m an owner o f property who bui Ids or improvesthercan,and
whocantmcts forsuch projects withucmtrsemr((l licensed pursuant to the Contractors ALTER (EA)
License Law. FEE SUMMARY
❑ I oro exempt under Sec. ,B&P C(or this reason OuTgrffrrrrr-
BACK FLOW PROTECT.DI7VICH SANITARY Y N
Owner Data DRAINS-FLOORROOF, CONDR13CEIPJ'#
, ,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y_N
❑ I hershy offmb that l have a cenificam ofernsent to self-i...rgern cenificum of I:I%TURES-PER TRAP RECEIPT#
Workers'Gnnpematioo Insurance or acinfird copy thereof(See.3800,Unit C.)which PARK PEE Y_N
nevem ell employee's under Nis p.I,. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(BA) PLANCHECK FEE
❑ CenifedcopyiaherebyfumishaL
❑ Certified copy is filed with Ne city inspection division. GREASFpNDUSTRI,WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not In completed ifthe permit is forum hundred dollars($IN) SEWER-SANITARY-STORM IA.200FT. ENERGY FEE
or less.)
I really that in the performance of the work for which this permit is issued,IAall WATER HEATER W/VENTpILECR
not employ any person in any manner so 2o *sub'e to the Workers' PAID
Co pensatlen 4M:of Culifom as -- 3 WATER SYSTEM11713ATING Dam Receipt#
O O Ppl!coot (/—
NO]'ICH TO PPLIC ff If er mu un nIficmc of P.xempuon,You'lam Id NEW RESIDENTIAL PLMB. SQ.FP. TOTAL:
In become subjecnoll or kers Compensation provisions of the Labor Cade,you must
fnnhwith comply tth such provisions or this permit shall be deemed invoked. BUILDING FEE
0. (] CONSTRUCTION LENDING AGENCY SHISMIC FEE
Vz I hercAyrfgrm Nm Vert iso construction lendingagency for the ped..cc.f
O the work for which this pemdt is issued(Sec.3097.Co.C.) TOTAL: ELECTRIC FEE
1-. Lenders Name
O U Lenders Address QTY. MFCHANICAI.PERMIT FEE
PLUMBING FEE
V 1 rectify that 1 have read this application and state that Ne above information is "
'�^ W correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorise representatives ofthis city to enter upon the CONSTRUCTIONTAX
U y .hove-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
t� (We)same to save,indemnity and keep harmless the City of Cupertino against
liabilities,' encs,cosmendo. I ym sy rattan...inaaaid City AIR HANDLING UNIT(01 ONX)CPM)
in canof he grand this t.
AIR HANDLING UNIT(OVER 10.00)CFNE
04!
rgnet o AFL' mr Date IDIHAUST HOOD IW/DUCT) PAID
N
AZARDOUS MATTRIMS DISCLOSURE HEATING UNIT GO 1N,"BTU) Dare Rettrpt#
W' e applicant or Nturt building nccupmt nom or handle hazardous mamrul
aside ed by the Cupertino Municipal Cede,Chapter 9.12,and Nro
e Health ti Safety HEATING UNIT(OVER IW,IXg)BTU) TOT
C ,Sem en 25532(a)P C3 Yes ❑Na VENTILATION FAN(SINGLE RESID)
BOILER-COMP LIKE OR IW,DN HTU) ISSUANCE DATE
WilDheapplic.nwrfuwrehuiltlinyoccupant use eyuipmenmrdeviceswhichemit p
bistrktl mandoes air conmminanls os defined by the Bay Area Air Qurlity'Manahgement
- ,OILER-COMP(OVER I00,000 BTU)
Jq P
D
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the barardous materials realulmments under Chapter 6.95 of the /. q
California Ilea d,&Safety Code.Sections 25505,25533 and 25534.1 understand Nm
if the building does not currently have a tenant,that it is my responsibility to notify the b I v1 ys
occupant of the requirements whieh must be met prior to issuance of s Cimificme of
Occupancy. f
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE