24580APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICA],
APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION
PERMIT NO. 24580 � � � 0
BUILDING ADDRESS: /('/�1 / /J a,,
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SANITARY NO.
APPLICATION
N SUBMITTAL DATE
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OWNIiRSf'AMIi PHONE:
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CONTRA�R'SNAMIi: . LIC NO:
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'ANCIIITECI'/ENCINEER: LIC NO:
ADDRESS4Act jrx' Y A.
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CONTACT: PHONE:
RICE
Q'fY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
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PF.RMITISSUANCE i
-A
LICENSED CONTRACTOR'S DECLARATION
c b (firm lhatlem licertscd under (Che ter9 (commencin th
rc ya provisions. p gwi
APPLIANCES -RESIDENTIAL
ID DESCRIPTION
PANELS
UPT020AM
Section ) of Division 3 of the puniness wd Professions Code, and my license is in
full force a. (Talo f I� /-/_ 0 4
License a —� LI0.M IN&W04 Y
Dam _ Contractor
201 11100 AM S
ARCHITECTSDECLAR N
l eaveRap ty uT she 1 s J as publi �xd .
If dk�
OV -R
slcrvs ELe cnL
SQ. FT. FLIXIN AREA $/SQ. Fr.
IN If.l
'v
rofexsi
OWN-BUILUERD NATION
i 1 h<reby eff1 Nat I em m the Convuctor'a License Lew fan dre
SPECIAL CIRNIi7MISC.yj
T E R
TEMP. ML•TER OR POP
following reason. (Se ion]OILS,Bminesc and Professions Code: Any city or county
which requires a pe Ito canarriaL.Iter, improve. demolish, mrepair anyamcturc
prior toiixisuunce,al.rreyuiree the applicant for permit. file .signed statement
POWER DEVICES T
that he is liceved pars onuo me provisions of the Cnmractor's License lsw(Chapmr
(commencing with Sation ]BOB) of Division 3 of ❑m Business onJ Pr.masionx GNe)
- -r.') VALUAA1TO
SWIMMING POOL ELECTRIC )XrE
ur that M1eisexcmpnhercfmm end the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Front subjects the applicant Ina civil penahy of
, �w�a�/
`i�,
OUT ITS - SWITCHES - FIXNRES
nm more than live hundred dollars ($500),
❑ 1,asowneroftheprnpcny,ormyemployceswithwagnaiheirwlecompmaiion,
NEW RFSIDEMIAL ELECfR _ SQ. IT.
STORIES
TYPECONSIRUCTION
will do the work, and thesrucmre Is not intended or- offered fromb,(Sec. 70W4, Business
end Professions Code: The Crearacmr's License Law docs not apply or an owner of
propnry who builds., improves thereomandwno does such work himsell'cr through his
wn employees, provided [bar such impnsvemems ate not intended or offemd for sale. It,
OCG GROUP
NES. UNITS
however, the building or improvement is sold within one yearefcompletion, the owner-
builder will have the burden of proving That he did not bui lJ or improve for purpnx of
QTY, PLUMBING PERMIT FEE
❑ I....wnerolthe Property,amexclusivclymnvnctingwithlicensW rontmctonm
F100DZONE
APN
vnsrum me proj«t (Sec. 7044, Bn.,mees and professions Code:) The Contmclora
License Lawdaesart apply man ownerofpropeny who build, or Improves themon,and
PERMIT ISSUANCE
who commets far such projects with a commom(s) Iicencel pursumto the Contractor's
License Lnw.
pLTBR- DRAIN&VENT - WATER FA
( )
FEE SUMMARY
❑ 1 ameaempl under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT #
Owner Dam
DRAINS- FLOOR, ROOF. AREA. COND.
WORKMAN COMI'IiNSATION DECLARATION
SCHOOLTAX Y N
❑ Iherebyaffirm thatI hove a cenificam.fcomme to xl6insum, or a certificate of
Workers Compensation Insurance oro cenilied copy thereof(Sec.3S00,Lah CJ which
RECEIPI'a
FlXTURFS - PER TRAP
PARK PEE Y N
covers all empl.,re s under this pemat,
Policy p
GAS - FA. SYSTEM -1 INC. 4 OUT-
RECEIPT k
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FTE
❑ Certifiedcopy is hereby famished.
GRHASLIINDUSTRLWASTFINTFRCF.PfOR
GRADING IEE
❑ Certified copy is filed with the city insp,dion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS PEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2001T.
ENERGY FEE
(This section need Nat be completed ifthe permit is forone hundred dollars($100)
or h s.)
WATER I[EATER W/VRNT/MIiCTR
certify the[i c sformanceaf the work for w ich this permit is issued, l chill
note toy w n in any manner so to bac to the Workers
PAID
Comps vtir x rf Cel r. Dat
WATER SYSTEM)TREATING
Dam Receipt It
Applies
NOT s O PPL[CANT 1, after melon his Cenifmute of [xemptin.. you should
NEWRESIDEM'IALPLMB. SQ.FT.
TOTAL:
comes Jwno the Workc'Com ion Provisions ofthe Labor Coda, you mus
forthwith ply wire such pmvisioan .this pertnitrshall be deemed invoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMICMF. w
J�
lhereb affimtthunhcre is aconsvuction lenJing agency for the perfn..aloof
the work for which this ppgng issued (Sec. 3(A], Civ. C.)
N R
TOTAL:
ELECTRIC I7EE
L
Lenders Nae
Lenderm
Lmders Address
QTY, MECHANICAL PERMIT FI7.E
PLUMBINGFFE
1 cenify that 1 have mad this application and state thin the above information is
rant. I agree us comply with all city and county ordinances and state lows relating to
PERMIT ISSUANCE
MIiCHANICAL IEE
building commuction, and hereby authorize representatives of thiscity to enter upon the
Imve meI sad properly forinspection puryexs.
ALTER OR ADD TO MSCIL
CONSTRUCTIONTAX
(We) agree to save, Imfira ify and keep harmless The City of Cupertino against
hob 'ties,judgm ,tests and expenses which y in my way same against mid City
AIR HANDLING ON] I'(TO 10,000 CEM)
co equen I'Ihe granting.( this pe
e��
AIR HANDLING UNIT (OVER IO,I]IIp CFM)
Sig re f pplicant/C nr Dem
IiXHAUST HOOD (W/DUCl7
PAID
HEATING UNIT(TO 100,1810 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt ft
Will th applicant., future building occupmrtsore or handle hazardous roared.]
zx deBmud by a Cupeninn Municipal GNe, Chapter 9.12, wd the Flealth and Solely
Code, Section 32(u)^
El Yes ON.
HEATING UNIT (OVER 100,TIIIO BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP CIVIL OR 100,1100 BTU)
ISSUANCE DATE
Q 6
Wi1llheapplicantoRumm buiidingoccupamuxcquipmenmr Mvica whichemit
Institutions air conmminwLa n d nest by the Bay Area Air Quality Management
District?
BOILER - COMP (OVER 100,000 BTU)
El Yes Nom
�j
DEC
NEW RESIDENTIAL MECH SQ. FIL
1 have neat) the homrdomaterials requirements under Chapter 6.95 of the
a 1992
ulifomia Health & Seliry CNe, Sections 25505, 25533 and 25534. 1 undersand Nat
itta. Acting entlyhaveamam,theitismyrespns Itryit)morythe
C/Ir Ur
accopan f the ems which mus Halt veof a Cenificme of
,
GDate
I+l1r-CIT 14!��i
ISSUED BY:
rout o .gent _
TOTAL:
OFFICE