24495 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY nP CLPERTINUB lt"I f:-nI.CC I'RICA], PERMITNO.
APPLICATION/PERMIT PLUMBING E b1ERAPANICAL 24495
BUILDING DIVISION 1tUI1.DINGINI:PROd RC'1'IUEN'fIFICAT'[ON '
BUILDING ADDRESS: ln' l c SANITARY NO. APPLICATION SUBMI ITAL DATE
o 51 PARK RC.�-e' UN c�T LGf« I HR-47L,
OWNERS NAME: toeVS! C PH27 _'7 7 CO ;sASSCTOR'S NAME: LIC NO; N/C CONTROL«
ARCHITECI'/LNGINEIJt LIC NO: ADD V l/`�1rA'UNC, N #F 0 MP
ta
CONTACT: PHONE: (/ BUILDING PERMIT INFO
QTY. ELECTRIC PHRMI'I' FTE
JLUG
US ECT PaW-IMLB MECH
PERMIT ISSUANCE �� It i�
LICENSED thtIaCONTRACTOR's DECLARATION APPLIANCES-RESIDIiNIlttF
'1'IAL TTT"' J"''OtttiB 'C
PCZ IM1ercby affirm licensedunderproviOR's DECLARATION
(commencingwith r1 `
4100_ Section 7")of Division 3 ofthe Business and Pmfessim s Code.and my license is in PANELS \� J
GuE. full fmmeamdc t. L
�z� Licemc Class �� Ll l.lc.p J9&2.14 UPT02MAMPS t� II y �-�
w?y Doc R/ SQ.FT.
Contme 201-1000 AMPS _`
FmZ ARCIBTECTS DECLARATION OVER 1000 AMPS SQ.FI'.IROOR AiA /
ZOo+— landcrsmnd my planssbnll bcasedoapablic records.
OZ—O
G m t m SIGNS E1.IiC1 RICAL
6RICQ Licensed l'rmfessional OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/MISC.
Ck 01U 1 M1ereby affirm thin I em exempt from She Comfector's License Law for the
413 LLy following reason(Section 10315,Bilines it Professions Code:Any cityorcounty TEMP.MITI BR OR POLE INST.
01 which requires a permit to construct,abler,improve,demolish,or repair any saucmre
$. }� prior to its issuance,also requires She applicant for such Permit to file a signed statement POWER DEVICES
Q
that he is licensed pursuant m She provisions of the Contractor's License In.(ChumerTTVTV
tiX Po 9(commencing with Section 7NX))ofDivision 3 oflhc Business and Professions Code) SWIMMING POOL ELIiCI RIC U T EV AT1ON
4j^,n at or Nhe is exempttherefrom and She basis for the alleged exemption.Any violation of OVR,EfS-SWItCHF'_S-FI%TURPS
Z< Sectimr 7031.5 by any ap,licun,for a pc.I,subjects SM1e applicant to a civil penalty of
s$ not more than five hundred dobbin($500). NEW RESIDENTIAL ELECT .IT.
S
la, ❑ I.x owneroflheprop ay.ormyemployeeswithwogesauheirsolecomp nsalion, Q (RCIIiS YI'IiCONS"IRUCI'ION
i3= will do SM1e worlsand the structure is not imendedomffesed hostile(Sec.1014.Business
and Profusions Cole:The Contractors License law does not apply So an owner of
property who builds or improves thereon,and who does such work himself or through his
OCC GROUP RBS.UNITS
ownemployces,provided that such impmvementswenot inlcndednroffemd outside.If,
however,the building mimpmvcmem is sold within one year of completion,the owner-
builder will have the burden of prosingular he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE N'N
❑ Lus nwnerofthe properrY�mn exedusively cantraaing with licensed enmmmors Sm
carload She project(Sec.7014,Business and Professions Code:)The Cmancre rs
License Law doesnot apply loan nwnerofpropenywho builds or improvesHereon,and PERMIT ISSUANCE
who contracts for such projects with o conawtons)licensed puro untie the Cmotmnoh
License Law. AL'I'RR-DRAIN&V1zNI'-WAPR(EA) FEE SUMMARY
❑ I an exempt under Sm, ,B&P C for this¢ion O I';IDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dztc DRAINS-FLOOR,ROOF,AREA.COND. —RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
❑ thereby affirm that l have ocenificatenfconsent tuself-insure.or acenificate of FI%TURES-PER TRAP RIiCE1P1'«
Workers'Compensation Insurance or a certified copy theremf(Sec.3800.Lab C.)which PARK FEE Y N
crealle p Wadrull, oyn�/WPI 9 GAS-EA.SYS'I'EM-IINC,4OUTLETS �� RECEII'rp
PolicyN 1A I1 '`~—�! O" z - BUILDING DIVISION FEES
Cmmpan) N T GAS-EA.SYSTEM OVER 4 IEA) PLANCIIECK IEE
❑ Certified copy is hereby famished.
❑ Cenilied copy is fled wish the city inspection Division. GREASEANDUSTR6 WASTE INSERCE1TOR GRADING FTE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Phis seclionnzed not lroeorn,amd ifthe permit is formic hundred dollars($INS) SEWER SANITARY-STORM ISA.200FF. ENERGY FEF.
in lesx.)
I cenify that in the performance ofthe work for which this Permit is isaed.I shall WATER HEAVIER W/VENT/ELECTR
not employ any person in tory manner as to become subject to the Workers' PAID
Compensation laws of Cadifmmia. Date so WATER SYSTEM/TREATING Dat Receipt«
zZ Applicant
O NOTICE TO APPLICANT ILa❑a making this Cenificus mf Exemption.you should NEW RESIDENTTALPLMB. SQ.FT. TOTAL:
F nom-. becomo.suhjecl n, be Worker's Compensmian prov 2 is of1w labor Code,you most BUILDING 121117 Vs
�a
forrhwith comply with such provisions or Nis permit shall be decimal revoked.
(] CONSTRUCTION LENDING AGENCYSEISMIC FEE 6
2z I hcrahy diirm that there is acm,nonSion lendimgagency for lira performance of _ ELECTRIC FEE r
U O the work for which this permit is issued(Sec.3091,Civ.C.) "I
Lender's Name PLUMBING EEE
W F Under.Address QTY. MECHANICAL PERMIT FEE
V I ecn'dy that I have .it this application and Stam that She above information is MECI IANICAL FEE
W correct. Iva.,.comply with all city and county ordinances madam¢laws relating to PERMIT ISSUANCE IS /I
f" � building construction,and hereby randomize representatives alibis city Summar upon the CONSTRUCTION TAX
VZ above-mcmioned p,,,,.y for inspection purposes. ALTER OR ADD TO MECH.
(We7 agree m save,Indemm[ and keep s the City of Cupertino against
liabilitiad ms msu des n swhich harnil-yin any way accrue against said City AIR HANDLING ON IT(TO 10,NX)CFM)
in commju ISANis permit.
1%
Z AIR HANDLING UNIT(OVER 10. p CFM)
Obit moor Dat EXHAUST ISOLD(W/DUCT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE IfGTING UNIT(TO IOLM BTU) T17 C. -aa- Dat Rrecin,«
Will theapplicont or lunare building uccvpantunrc or handle haaardous mmcfial lSTATING UNIT(OVER 100,01)1 BTU) J'OT L:
is defined by the Capistrano Municipal Code.Chapter 9.12,and She Health and Safety
Code.Section 25532(a)7 VENTILATION FAN(SINGLE RISID)
❑Yes ❑No ISSUANCE PRTE
Will She applicammfdum buildingt¢cupantuseequipmentordevices whichemil BOILER-COMP(3HPOR IW,IXXIBI'U) l�{�
Intimations air contaminants as defined by the Bay Area Air Quality Manger¢d BOILER.COMP(OVER 100Atp BTU)
Council
❑Ye. ❑No NEW RESIDENTIAL MECH.—SQ,Ff.
I hove read the hazardous macriahs requirements under Chapter 6.95 of the O 1 9
Culifomiu l ludlh&Safe,,Code,Sections 25505,25533 and 25534. 1 an icntand SM1nt ��� lq
if the building docs out currently have a ananl.that it is my respomibility in acidify She
occupant of the requirements which must be met prim to issuance of a Cenifiat of ��
Occupancy.
Owner mr icalmr ed agent Dam 1. ISSUED BY:
OFFICE