24648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUILDING-ELLCI'RICA[, PERMITNO. 24648
1 A /�
.� BUILDING DIVISION APPLICATION/PERMIT PLUMI{IPG-MF:CIIANICAt. 2 /I 6 �I x
BUILDING DING PROJECT IBEN-1'IFICAITON L 't V/•� V
172 1
BUILDING ADDRESS: {w� , .F� �yw�►^�a�� a��yw..p SANIT ARY NO,P APPPLLFICAATIIOyNSS`UUBB tM�IIITTTAL DXFE�/S v�l�Y_tJYV a�� • 1.01 J, 1 v 1 �
pW NE: CONTRI�IOR'S NA LIC NO.
N/C CONI'HOhp
RCHITIiCT/ENGINEER: LIC NO ADDRESS: El
CONTACT': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG LEC!' PLUME MECII
PERMIT ISSUANCE / ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OCZ I hereby affirm that two licensed underpmvisinnanfChupmr9(commereing with JOB DESCRIPTION
I40C Secdnn]000)of Division Sof the Businemand Profession,Code,andnry lipase is in PANELS
F to full fora and icut.
QjDatenx Chas Lica
UP T02W AMPS
,i<- Da¢ Co.,.mr 201-MET)AMPS
F'z AHCHITEC'SDECLARATION SQ.FT.FLOOR AREA $/SQ.ET.
ZOtnq I undersand my plunsshar he,uxJapublicrecords. OVF.H 1(100 AMPS
OZ—�
F,_F SIGNS ELECTRICAL
-a hicenxJ Profeasionnl
Qy�J `
wQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOaU 1 hereby affirm that 1 am eaempl foam the Contractors License Law for the
1+131+-vFi following reason.(Section 7031.S.Business and Pmfexaions Cade:Any city or county TEMP.METER OR POLE INST.
whichot,the,apernin lu consma,dre,improve,denudi,eh,arrepmranywoucmre
L }� prior it)its iavuunce,also requires the applicantfor such permit to file u signed statement POWER DEVICES
W<C, that he is licensed pummmnm the provisions of the Comowmrs License Law(Chapter SWIMMING POOL ELECTRIC
rear 9(conamencing with Section]000)of Division 3 ofthe Business and Professions Code) VALUATION
o,,bar he is caempubercfrom and the hatia forthcalleged exemption.Any violation of
t%QSection 70315 by any applicant for.pwerituril aG,the upplicanuo,civil penait of OIfTLhTS-SWI TCIIfS-FI%TURES
not alhanfivehundreddellws(8501B.
�S NEW RESIDENTIALCLF,CTR _SQ.FI'. STORIES 'TYPE CONSTRUCTION
KFo tsowneroflhe pmpeny.ormyemployerswiNWagesastheirsolecompc tion,
iIld.lhework.mdtksimcwaismlintendedoroffemdfmWe(Sw.7B ,Busines,
and Professions Code:The Commerce's License Law does not apply 1.sea owner of
property whobuildsorimpmvesthemon,and whodoes such workhimxlforthrough his
OCC,GROUP RES.UNITS
two employees,provided(lntsuch improvements we not intcadedoroffcrcd forwic.If,
however,the building or improvement is sold within one year ofeempletion,the owner-
builder will have the burden of proving that he did non build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[D1.asownerof(hepropeny,ameaclusivelyconvactingwithlicenxdc..0 1orsto
Itit—
onsouct lire pmjal(Seu.7044,Ravines,and Professions Code:)The Convector's
License Law does not apply loan owner of propertywhobuilJ,orimprnvca thereon.unJ PERMIT ISSUANCE
wmetworactafora.ch pmjecrswilM1aconlmdorta)licensed pursuan lothe Contractor's ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
License Law.
❑ I am exempt under Rcc. .B&P C for this teaaon BACK PLOW PROTECT.DEVICE IDE FIEFS
SANITARY YN
Owner Data DRAINS-FLOOR,ROOF,AREA.CON D. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
❑ Thereby affirm that l have a certificate ofewaxntto self-insure,or a arnifcate of FIXTURES-PER TRAP RECEIF'Tp
PARK IEC N
A0,
Workers Compensation Insurance,w.certified copy thereof(Sce.3800,lab C.)which RCCEIPI'a
covers all employee's under this permit. t GAS-EA.SYSTEM-I INC.4GOUT.ETS
BUILDING DIVISION PCT:S
Policy a
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI113CK FEE
❑ CenifederpylshercbyfumisluM.
❑ Certified copy is fled with the city inspectiondivi,ion. OREASIANDUSTRL WASTE INTERCEPTOR GRADING IEE
CER1117TCATEOFC%EiMPfION FROM WORKERS' GREASCTRAP SOILS IEE
COMPENSATION INSURANCE
This section neednol be completed ifthe Permit is frrone hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY IEC
or lass.)
I certify that in the performance of the work for which this permit is issued.)shill WATER HEATER WirVEITTJELECTR
not employ any Perwn in any manner so as m become subject 1.the Workers PAID
Compen,mion Lawsof C.Iifomia. Dae WATER SYSTEMaRFATING Due Receipla
zz Applicant
0 NOTICE TO APPLICANT:ILaTer making this Curificuta of Exemption,yo .ward NEW RESIDENTIAL PWIL SQ.FT. TOTAL:
V] becamcsubjectto the Wmkcrs Compensation provisions of the Labor Cade,you must
� ; forthwith comply with such provision or hispermit shall be darned my.ked. BUILDING FEE
C. [] CONSTRUCTION LENDING AGENCY � SEISMIC PEC
n z I hemby affirm that is a construction lending agency for the performance of
the work for which this permit is issued(Sec.309].Civ.CJ T ELECTRIC PEE k
U Lenders No. PLUMBING FEE
Lcndw's Address QTY. MECHANICAL PERMIT FEE
O U I ecrify ohm 1 h:rve read This.ppllc:nion and,lac Phut the above information is MECIIANICAL FF,E
W eonecl.lugree no comply wish all city and county oMinances and atmel�ws rela0ngm PERMIT'ISSUANCE
I'^ d buildingconsvuction,andhemby.uthon'mmpresenativesofdtlscitytocnleruponthe CONSTRUCTION TAX
U Z above-mentioned proPcny for inspection purposes. ALTER OR ADD TO MECH.
(We).gree to on,indemnify and keep harmless the City of Cupcnino against
liabilme,judgmc . and ea-mases wry ace against said City AIR HANDLING UNIT(TO 10.W0CFM)
umseyuenc It doling of lhkrp Too.
AIR IIANDLING UNIT(OVER 10.000 CFM)
nU 30-
ApplicamusCuntmnor Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('TO 100,000 BTU) Date Receipt is
Will the applicant or future building occupant slow or handle hasmdns material BEATING UNIT(OVER 100,0!10 BTU) A
as defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
I Code,Section 25532(e)? VENTILATION PAN(SINGLE RESIDE r
❑Yes ❑No I ISSUANCE DATE
WilllbcaPPliwnlorl'utcbuildinb(mcupantuscc4uiptncntmrdevia,whlchcmll BOILFR.COMP(3IIPOR 100,00011M)U)
hauNour sir comnminunts as tkfncd by the Bay Arce Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? P
❑Via, ElNo NEW RESIDENTIAL MCCII. SQ.Ff. B
1 have read Ibc baeardous materials requircmcnls under CIw b.r 6.95 of the ®(�^
Califnmiu Health&S rkty Code,Sections 25505,2550 and 25534. 1 understand Thal `` 0
if the building does or curently have a anon,ohm it is by resyonsibiliny m notify the ,n/Ql
occupant of the re9.imenwas which must be met prior to issuance of a Certificate of V�/ 3(3'/,/7
Occupancy. r` 1 .
Owncrornadaniad agent Data TOTAL: ISSUED 13Y: y Irytr
OFFICE