24886 I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /r�1
CITY OF CUPER'PINO BUILDING-ELI:C'1'RICA], PERMIT N
BUILDING 13[VISION 024886
2l H H/y��V
APPLICATION/PERMIT PLUMBING-MECHANICAL.
III111.I11NF PNWECf, IDI?NfIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
41 � 3 -�
e GNIrX LOT
O $N ME: ��1 PHONE: CO ¢I' R'S NAME: LIC NO: N/C C M'ROLal
AR HITECT GINEER: a/W5, LIC NO: ADDRESS;I: ar. - ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
S �S_S—ZSJ7 PF.RMITISSUANCE BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz IheMbyaffimthat lamliM.xcdumdcrpmvisionsofChaptv9 Brommeneing with
s�100 Semina]111X1)of Division3 of the But and Professions Cade,and mylicensc is in PANELS
Ffull force and effect. UPT020DAMPSyde /
GV License Class Lic.# 1
m L Dale—Conqueror. 201-HIM AMT'S
7ONZ ARCHITECT'S DECLARATION LQpIYAp�
FN�O IundcrsnnA my plans shell ho used us public rtcords. OVER IgM1AMPS rN 11 [�' yL� ICs' f0.J7
.� SIGNS ELECTRICAL \V'1 C rf��
RNQ .8 Licensed Professional n E
00,5 OWNER-BUILUIiR DECLARATION SPECIAL CIRCUIT/MISC. U 1 ) MPU L.�
O e. 1 hereby affirm tout 1 am exempt from the Conrad s's License Law for Be 3 I
1+13 tr-tn following Mason(Section 7031.5,Business and Professions Code:Any city Or county TEMP.METER OR POLE INST. 6 ,�rlJ7
E:Cao' which requires a permit m consumer,alter,improve,demolish,m repair any suueture
S.�W}
prior to its Issuance,also the licant for such lateral file asi ed statement POWER DEVICES is '� ATE
M�WjjS p squires pp pcmti gn V
Q O that he is hrmsed pursuant m the provisions of the Contractor's License Lew(Chapter
'm 9(commencing SWIMMING POOL ELECTRIC
oLL ( gwith Stttion]Otp)uf Division3 of the Business and Professions Code) VALUA'T'ION
yXj❑y or that he is exempt therefrom and the hasisfor the alleged exemption.Any violation of OIITLf;TS-SWITCHIS-FIXTURES O (/A 0
�yo Section703Lct
5byanyopplicam foraperoula,hjcs thcupplicunnoacivil penalty of
not more than Eve hundred do11ars(550D). NEW RESIDENTIAL ELECfR —SQ.FT.
W m ❑ Laxownernfthe Property,ormyempinyeeswith wugcaastheirsole eompevation, S RIES TYPECONSTRUCDON
W
will do the work,and the svnmurcisnot inteadedoroffercd forsale(See.7(104,Business
and Professions Code:The Commences License Law does not apply to an owner of
property who builds tar improves thereon,and who does such work himsdf or through his
own employece,provided that such improvements mart immtudedoraffemd foraele.If. OCCGROUP RES.UNITS
however,the buildingorimpmverm nt is sold within one year ofecmpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of I 3b,"P '
rola).
❑ I,asownero(thepropcny,amexclusivelycontaztingwiNticensedcon=tomto Qom' PLUMBING PERMIT' FEE FLOOD ZONE APN
conanuo the project(Sec.7044,Business and Professions Code:)Tim Contractor's
I.icercse Lawdaesntnapplytaanawnerofpmpeny who builds or improvestiferecn,and PERMIT ISSUANCE -QO
who contracts forsuch projects with acamo nce s)licensed I unmet m the Contractors
License Low. ALTER-DRAIN&VfiNT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OLMSIDHFE�
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,Rt]OE,AREA.COND.
WORKMAN COMPENSATION DECLARATION SO300L'TAX Y
❑ Iherchy effum thud haveacertificme ofennsem meelGinsure,arurenificaw Of RECRIPT#
Wmkerd Cooperstown Insurance oracenificdmpy thert00
of(See.38 .Lab CJ which
FIXTURES-PER TRAP �Z.O PARK MR Y N
covers all employee's under this permit GAS-EA.SYSTEM-]INCA OUTLETSRECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME
❑ Ceni(ies copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASE(INDUSTRLWASIEINTERCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be complemd ifthe permit is forma hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this pemdt is issued,I shall WATER HEATER W/VENDELECIE
nut employ any person in any m s.o as to become subject to the Workers PAID
,Z Compensationl.oweof California. DateWATER SYSTEMMEATING Data Receipt#
Applicant
O0. NOTIC13 I'O APPLICANT:If.after making this Certificate of Exemption,you should NEW RFSIDP.NTIAL PLMB. SQ,FT. TOTAL:
F-' U) become subject to the Worker's Compensation provisions ofthe Labor Code,you must
� ; forthwith comply with such provisions or this forms shut[be deemed awaked. BUILDING FEE �e0
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE s v(
1 hereby affirm that there is u construction lending agency(Or the performance of
L) O�+ the work for which this permit is issued(See 3097,Civ.C.) 17ae0 ELECTRIC FEE 6-S
IT, t-' Lender's Name �gf
I,ado's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE z•8v
V I sanity that I have read Nis application and sum Char the above information is w
acorrect. l agree to comply with all city and county ordinances and state laws relming m PERMIT ISSUANCE d D MECHANICAL HE _VQ
building construction,and hereby authorise representatives ofthis city Meurer upon the ]] CONSTRUCTION TAX
L) ubove-mcmioned propeny for inspection purposes. ALTER OR ADD TO MECH, - u O
We)agree to save,indemnify and keep harmless the City Of Cupe rinD against
Imbuwes,judgarems,case dexpenses.i.ch may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
inqua ce of the grgoT pppuspermit
AIR HANDLING UNIT(OVER 10,0M CEM)
grj�.ture of AWii tradelfatracri Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,OOD BTU) Date Rcceipt4
Will theapplicant or future huilding occupant store or handle havrdous material / ONDa
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVRR 100,000 BTU) TOTAL: /''�
Code,Section 25532(a)]
❑Yes C1 No VENTILATION FAN(SINGLE RFSID) �.0d
Will @eepplicant or futurcbuildingrxcupanmseequipmemordevices whichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Qualiiy Management
Uistda7 BOILIiR-COMP(OVER IM."BTU) � p B
❑YeA
Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
Ill...read the hazvdous materials oap iremems an&,Chapter 6.95 of the C��R 19 1993
California health&Safety Code,Sections 2550.1, rsa
25533 and 25534. I undersand that
if the building docs not currently have a Muhl.that it is my reapearsibilhy to notify the
,we upa.I of the requirements which most be met prior I.issuaPoe of a Cerificme Of n`1 I Vf Uf Ch 1 IITI/
Occupancy. V
r
Owneroramhmiaed agent Date TOTAL: 3 g ISSUED BY: w—c
OFFICE