24895 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOII II,DIN(.-ELLCI'RICAL P17RMII'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ^4 o J J O(J C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAATTIBON.SU-BMITTALDATE
UNII'b LOI'a /rya
OW i NAM! PHONE: CONTRA OR'S I' 6 IC NO: —
N/C CONTROLb
i
• ARCIII 'ECLEN EER: LIC NO: UDRESS:
CONTACT: PHONE;: BUILDING PERMIT INTO
2a z1 0'4 Fr QTY. ELECTRIC PERMIT FEE
BLUO ELECT PLUMB MSCI
PERMIT ISSUANCE El E
LICENSED CONTRACTOR'S DECLARATION ES-RESIDENt1AL JOB DESCRIPD /
pyy Ihereby 00T.I'imuhmi nmliccnscdundcrnd Pr fesso.,Csl r9(c mmag wi0
WiJ00 fail most.
effect. Jnf,M1C Business and Professions QNe, license is in PANELS
y�1-. full Torecan effect.
U V UP'f0200AMPS
(S.ZIy ]):It. C Lic.x
y6�• Unlc Commcmr 201.1000 AMPS v `'
ZONZ land Y sn HIT SUECL 'I' N OVIiR 1000AMP5 SQ.FT.FLOOR AREA $/SQ.TTI'.
o,-
P4 _J //' SIGNS ELECTRICAL a l
aa Licer canna s u v
KOyQ OWNER-Beirld from theCoATION SPECIAL CIIICUII'/MISC. _
U I hereby n,Se that 1 am exempt from the Contmcmrs c:Ana haw for the Ik'��'�(
IA3n-vFi following rtawn.(Seainn0W 15,Business and Professions CtMe:Any city or county T[MP.METER OR PoLf:INST. `- t � tl, IJ �`J I — 4
oFo.O¢ which requires a permit to contract,alter,improve,demolish,or repair any structure L5-3
prionobs lsxuunee,also reyuires the uppOcvm tart such pcmainn file asignedsmtnmem POWER DEVICES
W__<O that he is licensed pursuant to the provisions of the Contractors License Low(Chapter
Ct SWIMMING POOL ELECTRIC DA
aaoz 9gommencing isexemwith therefrom
andthe Division Jofthe ed exess and mption.ProfessionsAny .l.Cod.) ATION
tK„ nnhm h.lseae 7031.5 by aherefrnmandtnancrmi,for lmro,gedexeriao to.Any violation of OUTLETS-SWITCHES-FI%TIJ
�a¢ Sen ware th.lby hundred
dollars($500). .vuhjcctx the applicunuoacivil lxnnhy of '
�3pnot mom than five hundmJ Jolters(SS(N0. NF,WRFSIDENTIALELECTR SQ.FT.
❑ 1.aowneroftheprnpeny.ormyemplaymswithwaguas irsolecompensmion, S'T'ORIES TYPE CONSTRUCTION
will Jo the work.and the he Cnre is not imendMo Law div forvl.(Sec.7044,Bushreof
and Pndessions Codc:'fhe Comrocuor's License how does nrn upp1Y m an owner of
property who builds art improves Nercon,and who does sucM1 work himself anhmugh his
cmploYtts,providW that xuchimprovemenu ae not in¢ndedoroffemd forsale.If, OCC.GROUT' RBS.UNIT'S
however,the buildingor improvement is sold within one yemofcompletion.the owner- TOTAL:
builder will one the burden of proving that he did not build or improve for puryose of
sale.).
[:1 Lasowner of the pem
lnony,aexclusivdY contracting with li<ensW contrn
aorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE AI'N
construct the project(Sec.700.1.Business and Professions Code:)The Contractors
License Lawd«s not applymmmownendpmper,y whobtildxor improves thereon,and PERMIT ISSUANCE
who contracts far such Irrajects with aannmemr(s)licensed pursuant the Commemea
License Law. ALTER-DRAIN&VFN'1'-WATER(E3 ) FEE SUMMARY
❑ 1 am caempt under Sec. .B&P C for this ravenBACK FLOW PROTECT.DEVICE SANITARY Y DB i13 N
Owner Date DRAINS-Iq.00R,R(RJI,AREA, RECIiIPI'b
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
❑ I herebyaffirm that l have acenificate ofermsent toself insum.ora certificate of FI%TURES-PIiR TRAP RCCI,IITis
Workers'Compensation Insurance or v certified copy therewf(Sce.3800.Lab C.)whieh PARK hF.E Y N
rs all employee's under this petit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
m
Polity b BUILDING DIVISION HE'S
Company GAS-EA.SYSTEM-0VER 4(EA) PLANCIIIiCK HE
❑ Certified copy is hereby furnished.
❑ Cenifnl ropy iv filed wish the city inspeninn division. GREASEnNDIJSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF E%EMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
("is section need not he completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-S'1 ORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfomaan (the work for wbichthis pemtit is issued,Ish.11 WATER HEATER W/VFNI'/F,LECTR
not employ a y pe n y m b'ect to the Workers PAID
Compcnmmn ha of ulil'or Ilxlc6 ^� E WATER SYSTEM/TREATING Date Receipt#
O Applicata e ��
NOTICETU APPLICANT:ILaRcr making thisCmificam of Exemption,you should NEW RF_SIDIiNTIA1,PIN B. SQ.Fl. TOTAL:
Z N become subject to the Workers Compensation Provision of,hc Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Ow. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a convection lending agency for the performance of
O z the work for which this permit is issued(See3017.Civ.CJ TOTAL: ELECTRIC FEE
U O Lenders Name
(- F Lender's Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
U I certify that I have rtad Nis application and state that the above information is MECHANICAL FEE
>w W correct. l agree to comply with all city and county ordinances and sone laws relatingm PERMIT ISSUANCE
Fy building construction,and herebyauthnrlee representatives oftbls city to enter upon the CONSTRUCTION TAX
U Z shave.mentioned property for inspectpurposes.ion purses ALTER OR ADD TO MECI1.
(We)agree m save,indemnify and keep harmless the City of Cupertino again,
liabllioies,judilIs<ostx dex hick yinanywvyaccimeagaintsail City AIR HANDLING UNIT(TO 10,000 CFM)
in cunWum of c• It
t'
Y AIR HANDLING UNIT(OVER Ht)CFM)
rid
- tiig vture of Appbcant7Cnmmetar Date EXHAUST HOOD(W/DUCT) PAID
IIA'J,ARDOUS MA'I ERIALS DISCLOSURE 11 EATING UNIT(TO 100,000 R'1'U) Date Receipt#
Will the applicant or future building occupant store or handle hsrnrdous material HEATING UNIT(OVER 100,000 BTU)
as defined bythe Cupertino Municipal Cade,Chapter 9.12,and,he Health and Safety
Code,Sec,LO 255s32m)? EI No VENTILATION FAN I SI NGLE RISS ID)
ISSUANCE DATE
Will thea lie torfuturcbuildin ,u.we mntordeviceswhichemit BOILER-COMP QHP OR 100,000 BTL)
• pP 8«cuhe quip
huardnus air cnmaninams as define)by the Hay Area Air Quality Management BOILER-COMP(OVER 100,IF41 BTU) ^I p 1
District? 6 D
11 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the haxvNous mmenals mgdrememe under CTapter 695 of the MAR 2�
Cithfi ram Ilalth&Solely Code,Sunlnns 25505,25533 mad 25534. 1 understand that, 1993
if thebuilding J«srte,m requirements have amove,that itis my issuance
Innotifythe
«the andbuilding
of the es not curve which mast be mer prior m issuance art a CI nloare he • Ur
Oceupancy.
Owncror uulboriud open, Date '1' ISSUED BY: Vk�
OFFICE