28437 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY nP CUPERTINO BI 11,111 G-KLF.CI'RICAL FERMI'I NO,
APPLICATION/PERMIT' PLUMBING PRNG.. I IDENNIGAL 2 p /I 3 7
BUILDING DIVISION BUILDING 1'Rf)JEC'I'IUE\"1'1NICA'1'1IM' O �F /
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0
O RG UNIT# 1.0'F _1
O 'tRS NAME: PHONE: CONTRACTORS NAME rY LIC NO:/moi
A f SS e� C / Z �O / ^ G (� D N/C CONfItOL
AAW RCHITECT(ExIGINL:R: LIC NO: ADDRESS: , / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT' FEE,
OLUG IihliP PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CON'1RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB CRIPTION
pmt urarchymmmmatIran f the Baaffeernd Pimoosorcnaode andmmeneingwhn �� ' �yl �C=
FOO Secdnn]IXIU)of Division Jol the Busincsa and Profs,sinns Gvlc,and my liwnac ini PANELS
Ili[[ fu'ifnrce:red eIfcet.
F<zW 'so �/ UP TO AMPS /�J' e�<SS
,Zu1 Licmase Class Lic.4 e.—.--ua—
to« Dam Contras m -- f 201-I000 AMPS
Fyy ARCHITECTS DECLARATION SQ IT.I:1, N IS S/SQ.FT.
ZOyz
1 understand my plans shall be used m public records. OVER 1000 AMPS
OZ-0
SIGNS ELECTRICAL
Licensed Professional
yvcif< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XC WU 1 hereby affirm that T an exempt from the Conlmcto's License law for the
W 3lL y following rennin.(Section]031.5,Business and Rofessiom Cale:My city or county TEMP.METER OR POLE INST.
E a 0< which requires a permit to construct,alter,improve,demolish,or repair any structure
pnormitaiasuunee,alsomquirtstheapplicam framch permitta
o flesigned nearer POWER DEVICES
,y <Cy that he is licensed puouaot m the provisions of the Comments's License Law(Chapter
a X.LX 9(commencing with Swims 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'DON
�_y or that he is exempttherefrom and the basis for the alleged exemption.Any violation of
Y Scetion 7031.56 permit subjects the applicwttoacivil penalty of OUTLETS-SWITCHES-1§%TURES
FZ< by dorm,($
ASO not mnrcthun Eve hundred dollars(SSW). NEW RFSIDENTIALELECfR _SQ.FL STORIES TYPE CONSTRUCTION
atw ❑ the
w work,anhepstruct.o is nota ad,,i withwagesaethcir sole cam.Btxinon,
yg� will dathen%Cde: he Contractor's
License La c doesed of apply
to 44,Boners
and Pmfeaainn.a Code:The ConmactoFs License Law does not apply to ire owner of
property whohuilds oriaipmvm'dmrcnn.and whodoev such work himself onhrough his
nployes,,pmvidcddawl-chimprovementsaanotintcndW orofferedf rnvle.If, OCC.GROUP RES.UNITS
honwever,the building or improvement is sold within one yearofcompletion.the owner- f'
bwmcr will have nm barren of proving that he did not build or improve for purpose of
salc.f. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lasso a pr sect(Sec.
70 am exclusively and Professionng s rabi On,ed Comemtoro
onnmet the project(Sec.to aAI,n
Business and Professions Carriponsc hemmanra
License lawdrcnnot apply mun uwnerofproperry whobuildsurimpmvesthercon.and PERMIT ISSUANCE
whoconamesforsach projects.ldffemrad.00 licensedpursuannothe Contracmrs
license law. ALTER-DRAIN&VENT WATER(LA) IlC SUMMARY
❑ I am cxempl under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY
FE&S
SANITARY Y N
Owner Date DRAINS-FLOOR.RODE,AREA,GOND. RECEIPTis
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that l have a certificate ofconsem tocolf-insum.ora cenifcateof FlXTURFS-PCR TRAP RECEIPTp
Worker.'Compensation Insurance or ecertifirG copy thereof(See3800,Luh C.)which PARK EEG Y N
rs all employe Cr nde t ' permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
'.over,
ahp eZ BUILDING DIVISION FEES
Cootpm, GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Cerified ugry is hercy fumi.md.
[:1CcelOed copy is filed with the city inspection division. GREASEBNDUSTRL WASTE IMfHRCEPfOR GRADING FEE
CER'1'IPICATIi OP EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE.
COMPENSATION INSURANCE
('Ibis sa:uooneed not he completed if Ne permit is Intent,hundred doll urs(EIW) SEWER-SANITARY-STORM HA.20047. ENERGY FEE
or lcsx.l
I cenify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ my person in any manner as to become subject to the Workers' PAID
Compenaainnlawsof California. Date so WATER SYSTENUTREATING Date
Z Applicant
O NOlican TO APPLICAMT:IL after making this Certificate of NEWRUIDENDALPLMB. S .FT.Exemption,you should Q tOTAL:
f—' W became subject m the Worke(s Compensation provisions ofthe labor Cale,you must BUILDING FE
� > forthwith comply with such provisions or this permit shall be deemed revoked.
00. [] CONSTRUCTION LENDING AGENCY SEISM
I hereby affirm Not hem is a construction lending agency for the Performance,of
U O the work for which this pcmrit is issued(Sec.300,Civ.C) TOTAL: ELE 1 E
I<nam's Name PLUMBING FI
V0 F Lenders Address QTY. MECHANICAL PERMIT FEE
U I cenify that 1 have read this application and state that the ni informmion is MECHANICAL EE
comet. I agree it)comply with all city and county ordinances and stat lows relating m PERMIT ISSUANCE
F building construction,and hereby authorize opremalowesof Nis city to cmcofpon the CONSTRUCT NTA%
U Z ulnvomemloned pntperty lin inspection purposes. ALTER OR ADD TO MECIL
(We)agree to sane,indemnjfy and keep harmless the City of Ca,rtino agairvm
hataitics,judgnams.nvslx and cxpcnaee wM1ich may in anyway.,,mr.Sua,l mdCity AIR HANDLING UNIT(TO 111,001 CFM)
in cmve,au ,,c or the li anling of(his peril.
AIR HANDLING UNIT(OVIeR III,0N)CPM)
Signalamof ApidemUConlracmr Gum EXHAUST BOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dat° Receipt#
Will the applicant or fumed building occupant some,humane hmmdoas amen.( I'OT
HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cote.Chapter 9.Q.and the Health add Safety Aw
Code,Section 853201? / VEIsEEATION FAN(SINGLE R[SID) 'Y
13 yes BT
BOILER-COMPOHPORIW,00h)BTU) . ISSUANCE ATF)
Will the appmmunis Ntumbuilding«c the uy Ares Air Quality Mwhichreat S)prm
M1aurdom trim aomaminanta m acfin by the Bay Arta Air Quality Management BOILER-COMP(OVER IW.000 BTU) `((�/`
District?
❑Ycs No NEW RESIDENTIAL MCCn. SQ.Fr.
Clry� 9�
1 have mod the hazankm,,mamnnls requirements drat,Chapter 6.95 of h �UNt
Callfomic Ileahh&Safety Code,Sections 25505,25533 and 25534. 1 understand that 140
if the huiliiag does not,unewly have a mmol,th ey res sibllaymnntity the Jh+rY(]
upum Illmym ulrcmI
ut,of u C i more of
U anc
O or uthaim I Dam TOTAL: ISSUEDBY: \�(j`�` •'y,YY'`x`
OFFICE
_ e ; . ✓ /
//f ( Al /
lz
LP
0 -\\ }k ! ; ! / ? /
/ w CZ @
7 }
2 �\\ƒ} \
/� � / `
ƒ /
� & 6 �
f { /o .
7 0 0FD _ ` ' •
\ �) B `
� � / Z � � , } � r
-
, ! }am : / % \ $ [ 0
- rtlg
) ( [ ;rx
_ -
) } ,} B . ; § !
`
:z \ } \ \ ( 9 0 m
J 0 \! ! #
° o
}}} }
� } .