24884 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLECI'RICAL PERMITNO. /1 /I H H
APPLICATIONIPERMIT PLUMBING-MECHANICAL L LI
BUILDING DIVISION 1.7,'BUII,DINGPROJRC'I'IDRNTIVICA'I'ION
BUILDING ADDRESS: ' SANITARY NO. APPLICATIONSUUBBMITTTALLD�ATE
/ UNITp LOT# 3����1/Y 1
O EBS NAME: PI{0 E: C RACTOR' WE: LIC NO:
` — T a 0 ^CON�1
ARCHITECTIENGIN-.R: ,ICN , ADDRE S: w J
CONTACT: — '���7-//pp'''T��1,,,,pppp'''' PIION': ? _ BUILDING PERMIT INFO
4 I j.jL T - Q 'Y. ELECTRIC PERM T- _FEF. .
A%r BLDG EL PLUM MECH
ITT IIPP�I VV Y O ITp PCRMIT ISSUANCE' `��
LICENSED CONTRACTOR'S DECLARA ON APPLIAN :S- ID AL JOB'DESCRIPTION
Ron•z Ihercby affirm thmlunlittvedunderprovisions ofChepter9(cit becingwith
0W0❑ Serunn 7000)of Division 3 of the Basi..and Profession,Code,unit my license is in P NE /
full force and effeco c FPD //
<yyW License lusx Lia# ( T' AMPS
z�i6a Dam Contmctor -Uyd)AMPS
4--K ARCHITECTS DEC T10N I SO,FT*FLOOR AREA S/Sp,[el'.
Z Ow 0 1 undmmnd my plans shall be used m public rcmrds. OVER 1000 AMPS
OZ-0 �pVs
SIGEL 1.
Licenced Prufcssi.nal
OWNER-BUILDER DECLARATION SPE AL '1 C T C. ' D u r
iqS E a F 1 following
affirm that 1 am exempt from the Contractor's License i for th v
P+ ;w j which inguiresa Section 7031.5.Business alter,
and improve,
derions lish.-: ,onny city or Ly :R OR ,NST.
C,MO7 which it.requires rowne,thoalmgin far
Permit
Eu�Q0 that he sliimarrcensed palsont to the
thevisios of the Co pemtinofleasi. smtement RDF.V, v
�' pK that he is licensed pursuant m the),d Di,akofrhe Contractor'.License Luw(Chapter
L o4. 9(commencing with Section?0(q).f Division3 Juries Business and Professions Code) INNING POOL ELECTRIC VALUATION
,_T'/
_y a that he is exempt therefrom and the basis for the alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURESOlk W r
t,a Section 70313 by any applicant far.permilsubjceu theapplicammit civil penalty.( 10CV. ./`
g Q not marcthanfive rofthedre ay,ormyemp. NEW RESIDEN'DALELEM —SQ.Pf. y
le.�i7 � ❑ I,us.wrk,and
Smany,.rmyempeadmorithwed fortthcirsolecompcnsnion, STORIES TYPECONSTRUCTION
a will dothewon,and the he Care otic.Limdnrawdofor lap ply 7044.Business
and property
wh ono Cade:The Contractors License Low does n.l apply to an owner of
as
owaroywyers,pdsvrimpmvesthm.asndwhodases mothi adclomulfur formic.
OU NITS
ownemployes,provides that vert ant is s emems areure inoosedmoffered formle.IL
however.the building orimpmvememissoldedidnot year or improve for
themorm
builderder will have the burden afpmving that he did not build or improve for puryuw of
ale J.
❑ I,us nwnerofthe pmpeny,am exclusivdyconhacting with licerrome atm tact. QTY. PLUMBING PERMIT FEE. D NE A
PNI
com orct the pmject(Sec.7044,Business and Professions Code:)The Contractors PERMIT ISSUANCE L
License Lawd«anmapply to on.wnerofpropcdy who buildreaimpownflrman,and / v
DATE
whomatracu fmsuch pmjecu withi minism.c.)licensed Pa...,1.the Contractor,
License Law, ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Cl I um exempt under Sec. ,B&P C for this reasonBACK FLOW PROTECT.DEVICET DE FF...
SANITARY Y N
Owner Dote RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR.ROOF,AREA,GOND. SCHOOLTAX Y—4—N
ElIhembyaf mthmlMveacmifcamo(consentwnif.insure,orame ifcam.f FIXTURES PER TRAP RECE
m
Wori Compensation lmunceor a cenif¢d copy thereof(Sae.3800,Lab C.)which PARKFEE Y N
covers all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEI #
Policy# �� BUILDING DIV ION RM
Company GAS-EA.SYSTEM-OVER4(HA) PLANCHECK FEE N
❑ Cmified copy is hmby famished.
❑ Cenifed ropy is fled with the ciry impaction division. GREASFVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASHTRAP SOILS FEE
COMPENSATION INSURANCE
(ThissecimnneN notbecompleted ifthepeamitisformalmadmildollars($1M) SEWER-SANITARY-STORM EA.MFT. ENERGY FEE
or less.)
I cenify that in the perfnmmnce f,he work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIR
not employ any person in any manner m as to.becoma subjecl to the Workers' PAID
Compensation Lawe.f COTimnia. Date WATER SYSTRMfrREATING ate Re •ip
O z Applicant
Z 0 NOTICE TO APPIACANT:If,mm,making this Cemffimreof ExemptiorPear should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
F In forthwith
comply the such
res Compeor Ohl, the Labor Code,you must
a ; forthwith comply with such pmvisiom mrhis permitsMll bethermal invoked. BUILDING FEE J
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thatthem is a construction lending agency for the performance of T
U Oherebythe work ec
for which this pencil is issued(S .3097,Civ.CJ ELECTRIC EEE (A
J
lenders Nome
0 U Limbers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LII1 certify that 1 have read this application and state that the above information is MECHANICAL F E
correct.l ogmew comply with all city and county ordinances endstate laws eltaingtu PERMIT ISSUANCE'
rA buildingcrostmetioaandhembyauthori=mpraenmflvesofthischymmicruponthe CONSTRUCTIO TAX
U Z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmenu,costs and cxpemes which may in any way accrneagaiimmid City A IR HANDLING UNIT(TO 10,0910 CFM)
in emse,;ceof the gmmingnfthispennit. (�.s,s -
_0162 AIR HANDLING UNIT(OVER 115,00CFM)
w of ApplicanUContmcor Dme EXHAUST HOGG(WIDUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IMIfg0 BTU) Dale Receipt#
Will the applicants Town ...Not,ame handle hazardousmalarial HPATINO UNIT(OVER 19X1,000 BTU) O
m dcfnW by the Cupertino Municipal Crile,Chapter 9.12,and the Health and Safety
IM
Code,Section 25532(e)?
13Ya 13 N. VENTILATION FAN(SINGLE RESID) 1011y 11101,
❑
ISSUAN TATE
Willthca Icanwrfmurebuildin cu unmuc menmrdeviaswhichemft BOILER-COMP(3HPOR 100,(100 BTU) Rq �k }y
/ poi got' P' 9m. T A V
hazmdnus air cameminuntn as Defined by the Bay Area Air Quality Management BOILER.COMP(OVER 1 W,MN)BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. wf
I have read the hazardous anceriaB mcro
nupAres under Chapter 6.95 of the APR 16
Celifomia Health&Safety Code,Sections 25505.25533 end 25534. 1 understand that r
if the building does not currently have a tenant,that it is my responsibility to mai ly the
mcupent N the requirements which must be met prior w issuance of a Certificate of I. rrh I II
Occupancy. 6
Owner or authorized agent pace TOTAL: ISSUED BY:
OFFICE