24944 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELKCIRIGAL PERM'(NO. 24944
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AD RP S: �P \ R, UNITp LOTM SANI'T'ARY NO. APPLICATION SUBMITTAL DATE.
ill
OWN (yf�CJy/_ ` e ^I � PHONE CONTRACI'O 'SNAh3E: o / LIC O: ' 4
,J J 1B/� IllC N NIC CONTROL N
t.
ARCH1 /ENGINRER: LIC NO: ADDRFS 0 lo ❑
S. /
CONTACT: PHONE:
QTY. ELECTRIC PERMIT ITE BUILDING PERMIT INFO
BLDG ELECT PLUMB NIECE
PERMIT ISSUANCE ❑
LthatIsED COMRACfOR'SDECLARATION pppL1ANCFS-RESIDENTIAL ' C Iv
p fyZ (hereby affitLICENSE CONTRAC proviaDECL RAT( 9(cotmnencing with 111"•a�"'///�/�� _---� =aaasss� /��,�K)•\
�00 Seeion'/(100)of Division 3 ofthe Business and Professions Cale,and my littrase is in PANELS
CU full force and effect.
Qz License Class Lim.11 UPT0200AMPS
rotvai Date Contractor 201-10013 AMPS
z O to Z�, ARCHITECCS DECLARATION OVER IIXIO AMT'S SQ.IT.FLOOR AREA S/SQ.1T.
O z�❑ 1 understand my plans shall be used as public records.
QY
tlu SIGNS ELECTRICAL Ej Licensed Professional
LLyd'6 OWNER-BUILDER DECLARATION SPECIAL CIRCODUMISC.
i0.gS,Oim 1 hereby n.affirmSc that I am exempt from the Contractors License law for the �s I {�
f+13ioi following rensoo.(Section 0UJ1.5,Business and Professions Codes Any city or county TI3MP.METIiR OR POLE(NST. CP o0aad`
01 which requires o verna to c.morxt..1let.improve,demolish,or repair any structure
NYS prior to its issuance,ulso requires the applicant for such Pennit to file asigned statement POWER DEVICES
ty p Nat he is licensed pursuant to the provisions opine Contractors License Law(Chapter
d1p�' 9cammencin SWIMMING POOL EI.ECfRIG
S� ( exempt
Division 3e(Needexemptio .Any voras Cod e) Vp1.UATION
W—m or that he is exempt thcmfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
z,Q Section lOJLS by troy vpplicant forapemtit subjcets the epplicam tascivilprnalry of a
�SFE0 not momthan Bveire proddmlarmyem). NEWRFSIDENTIALELECIR _.SQ. TOR FS TYPE CONSTRUCTION
6� ❑ oche wrk,andepmpeny,orm otintndedorofwed for sale
7041, nsate,,x
a1y will dathewmk,and tire The Communes
onicense ow do fs no, pl,man BusinessPIZ
56
and Professions or The ChemLicense Law does not apply lf an owner of Y.
pmpettywho
yeasbuilds Proviidforat Nimphrodwhodoes such wak himmlforfwughhis CG P R TS
cmployecs,provided thatsuchint avild wit atenot intendedmoffered thesale.IL
M1uilder ,,th<bve thetorimprovement ishat edict of year or improve for the owner. TOTAL:
builder will have the b.Nen of proving that he did not build or improve for purpose of
1e')' Q'I'Y. PLUMBING PERMIT FEE FLooD ry APN
constra❑ Las the pounront(See.he 7y , Business anly comramsionng with lic,)Tvaensed contractors to
License th.oes not(Sec.oano Businessantiy who sinm C,on,n3se Conearrina PERMIT ISSUANCE /� v
License Law does not apply tanownerofpmpeny whobuildsorimproves thereon,and
Licenseho radsforxuch projects with acommctnr(a)licenudpunuannmhe Contractors ALTER-DRAIN&VENT-WATERHA) FEE SUMMA
License Law.
❑ I am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS-FLUOR,ROOF,AREA,COND. RECEIITg
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherchy afilrm thatlhave ucenifcum of consenuoselGinsnn:,mncenificate of RECIi]M'N
00 Workers'Compensationlnsumnceoraceriifedcopythereof(Sec.3tl00,Lub CJwhich FIXTURIS-PER TRAP PARK FET? Y N
covers all employee's under this permit. GAS-EA.SYSTEM.]INC.4 OUTLETS RECEIPT p
Policy 0 BUILDING DIVISION FEES
Company GAS-LA.SYSTEM-0VER 4(EA) PLANCHECK FEE
❑ Cenified copy is hereby famished.
❑ Cerificd copy is filed with the city inspection division. GREASRRNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectinnneed not becompleted ifihe permit is for one hundred!dollan(SIM) SEWER SANITARY-SI`0RM EA.200". ENERGY FEE
or le .)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENTIELE.CIR
not employ any punt. in any moons,so as to become subject on the Workers PAID
Z Compensation Lewamf mi
C.lifoa. Data WATER SYSTEM(IREATING Date Receipt#
Applicant
zp NOTICE TO APPLICANT:If,.Bermakiril Certifcomof Eaemptlon,you should NEW RESIDENTIAL PLMB. SQ.FT.. TOTAL,
Ln become subject to the Wmkoex Compensmin i provisions ofthe!.alb Code,you must
� > forthwith comply with such pouskimisor,hia permit shall be deemed revoked. wwamisw BUILDINGFEE
y (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
;D z 1 hereby afford that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec,3007,Civ.C.) TO ELECTRIC FEE
W. Lenders Name PLUMBING PEE
Lenders Address QTY. MECHANICAL PERMIT FEE
CU1 certify that I have read this application and state that the above information is MECHANICAL PER correct.lagree mcomply with all city and county ordinances and state lu
ews relating to PERMIT ISSUANCE
_ buildingconstmetion.and hereby authorize representatives ofthis city to enter upon the CONSTRUCfIONT
U ,7, above-mentioned pouchy for inspection purposes. ALTER OR ADD TO MECH.
(We)at m save,indemnify and ke harmless the Cit mf Cupertino against
liabilin dgme ls,costs and 'sw m yway c-.,ageinst said Ciry AIRHANDLING UNIT(TO IO,OOaCFM)
in sequ c mgmntin of Chi
keAIR HANDLING UNIT(OVER 117,00007M)
ignamre fApplica /Comms 1 EXHAUSTHOOD(W/DUCT)
PAI
HAZARDOUS MATERIALS DISCLOSUREJ HEATING UNIT(TO 100,000 BTU) Date ReceiptM
Will the applicant orfuwre building occ.pantamre or handle hvzr ousemakRal
a+defined by the Cupertino Municipal Cale,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU) L:
Code,Section 25532(a)1 VENTILATION VAN(SINGLE RESID)
❑Y. ❑No
Will he applicant nrfumrebviltlingnecupant use egnipmem nrdeviccs whichemit
BOILER-COMP(3HP OR 100,1100 BTI]) ISSUANCE DATE
havNws sir contaminnt
as as defined A.by the Bay AAir Quality Management BOILER-COMP(OVER 100,000 BTU)DiaMq? fir! 8
❑Ya ❑No NEW RFSIDIiMipL MECH.—SQ.Ff. 4�
1 have read the b Moos materials requirements under Chapter fi 95 of the ,(a�� q
Califumialfealth&Safer Code,Section. un
25505,255J3.nd25534. Iderstoodthat (t� qqa��
i1the buildingdocenot currently have.mount,that it ismy respmsihility to notify the
occupant of the requirements which must he ma prior or issuance of a Certificate of
Occupancy.
Owner or archaized agent Date TOTAL: ISSUED BY: I IV
OFFICE