24458 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEUT HICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24458
BUILDING DIVISION BUILDING PROJECT D)RNI'IFIC.ATION
put 16ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI Ti
MN ad UNIT LOT# I `�
CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
qW / \
ARC TIE ''/IiNGINEF?R: LIC NO: ADDRESS ❑ 41N.
CONTACT: PHONE:
QTY. ELIiCTRIC PERMIT FEE BUILDING PERMIT INFO
BO ELECT PLUMB ME❑CII
PERMIT ISSUANCE
LICENSED CONTNACTOR'Sionsor RATION APPLIANCES-IiIiSIDENTIAI. �rvl �� �
tXC Thereby uftirtnCMoro licensed CONTRACTOR'S DECLARATION
IO (commencing with 7L'_
00 Section 7007)of Division 3 of the Business and Professions Code,and my license is in PANELS
W66 full force and effect. 6
Fyy{ License Choo Lic.p UPT0200AMPS
mQco Data Compactor 201-IOW AMPS
Z.O D ARCHTTECPS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA SBQ.FT.
O G l- 1 undershoot my plans ehull be used as puhlic records. LED I N
(=m SIGNS ELfiCi'NICAI.
Q, -4 Licensed Professional
�ay.�6 OWNER-BUILDER DECLARA'T'ION SPECIAL CIRCUIT/MISC.
XOaH I hereby affirm Nat I am exempt from the Commoner License law for the C]
ki,s,is is
W 3C, following reason.ISection 7031.5,Business and Professions Code Any city or county TEMP.METER OR POLE INST. �'-'
Fp-�j g which requires a permit to construct,alter,improve,demolish,or repair any structure
loirsissuuncc,ulsorc the applicant forsah,amait to fileasi edmiacraent POWER DEVICES 30 /a
prior quires 11 1 6^
O Thu[he ie licensed pursuam m the provisions of the Cnntmmors License Law(Chapter 1
L o�' 9(commencing with Sectimn]IXp)mf Division Sof Ne Business and Rofessions Code) SWIMMING POOL ELECTRIC TION
_y or that he is eaempltherefmm and the basis for Ne alleged exemption.Any violation of OUTLETS-SWITCHES-Fl%TURKS
Z f Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of
£ O not mom than fivehundred
ny,c)rdelta. yam). NEWRESIDENTIALELECfR _SQ.FT. STORIES TYPECONSTRUCDON
311in eownerofthe property,nrmycmployces wiNwugesas Ncirsolecompensetion,
d Newark,andNe structure is not Intended oroffered Otranto(See.]I144,Business
at Professions Cade:The Convectors License Lew does not apply m on owner of
propenywho builds orimprovesthereon,and whodoes such workhimaelforthroughhis OCC.GROUP RES.UNITS
own employers,provided Nor such improvemems art not imandedor offered for sale.If,
however,the buildingor improvement is sold within one yeeri fcompletion,theowner- T
Fuilder will hove Ne nurden of proving That he NJ not buil)or imMove for purpose of
sale.).
❑ Lasmwnertd Neproperty,mn exclusivelycnmruming with licensedcommcmrs m QTY. PLUMBING PERMIT FEE Fl.00D LONE APN
construct the project(Sec.7044,Business and Professions Cale:)The Comractoia
License Lawdoes notapply an an ownernfpropvrty whobuildsor Improves thereon.and PERMIT ISSUANCE
whoccomisforsuch projects with acmntmctor(s)licensed pursuant o the Contractors
License law. ALTER-DRAIN&VENT-WATER IRA)
FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Nis mason BACK FLOW PROTECT.DEVICE IDE
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
t WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihemby affirm lhatlhave eccnifiwte ofconmmte selLinsure,oracertificem of FIXTURES PER TRAP RECEIPT Is
Workers Compensation Immature or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
Cans all employee's under this permit. GAS-FA.SYSTEMd INC.4 OUTLETS RECEIPT a
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYS TEM-GVFR 4(EA) PLANCI HECK FEL>
I[] CenifedcupyishercFyfumished.
❑ CeniOcd copy is Fled with Ne city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This aenion need not be cnmplcmd ifNepermio is for one hundred dollars($100) SEWER-SANITARY-STORM EA,200F7. ENERGY FEE
mless.)
I certify(hat in the performance ofthe work for which oils permit is issued.I shall WATER HEATER W/VENT'/ELECTR
not employ any Person in any manner so as to become subject to the Workers PAID
Z Compensationlawsmf California. Date WATER SYSMNERFATING Data Receipt#
Applicant
zO0 NOTICE TO APPLICANT:ILaOcr making this Ccnifica¢of Exemption,you should NEW RESIDENTIAL PLMB. SQ,Fr. TOTAL:
h become subject to the Workers Compensation provisions ofthe Labor Code,you must
Ki forthwith comply with such provisions or Nis permil shall he deemed revoked. BUILDING EEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affimr that hem is a construction lending agency for Ne performance of
V O Ne work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
lenders Name PLUMBING FEE
Q H lender's Address Q'rY. MSCI IANICAL PERMIT FEE
V I cerlfy that I have read This application and state that the above information is
acorrect.farce w coowith all cit unit ordinances and state laws relating to PERMIT ISSUANCH MECHANICAL ITEg Ply wi yon county g
_ Z adarvingenlioned i^^,had horinspattion p rpses. veenfthia citymenmrupon Ne CONSTRUCTIONTAX
L) z above-mentioned Pmpcnyfor inspection Purposes. ALTER OR ADD TO MECH.
(We)agate n save,indemnify and keep harmless the City of Cupertino id against
incomes,'uaunt nJ expects, it,hmay in any w, me ins iJ Ciry AIR HANDLING UNIT(TO IO,OW CPM7
m ansequcncx of e f guf thiol it.
AIR HANDLING UNIT(OVER 10,1100 CFM)
Si arae Ap a t ontr Da EXHAUST HOOD(W/DUCI) PAIDTI
HAZARDOUS MATERIALS DISCLOSURE // //��// Z HEANG UNIT(TO 100,000 BTU) Dam Receipts
occupant Will the applicant or future building store or handle h dnerial
os defined by Ne Cupertino Municipm Code,Chapter 9.12.and the Heath and Safety HEATING UNIT(OVER 100,000 B'IV) TOT :
Corte,Section 25532(x)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
Will Neopplicant orfutumbuildingoecupunt usecquipmeamordaAcawhichemit
BOILER-COMP(3HP OR HMNNO BTIH ISSUANCE DATE
rasdovs air confinements as definM by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
istrictT PAID
❑yes ❑No NEW RESIDIiNTIAh MECH. SQ.FT.
r 1 have reaA the hnradons materials rcquircmems under Chapter fi 95 of the NOV
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understnml that 1992
If
the building does not currently have a broad.that it it my responsibility to notify the y
occupam of Ne requirements which most be at prior m issuance of a CmiRwm of
occnpalley. Clow /•'. tl' VV
Owner or uuthorixd agent Date TOTAL: ISSUED BY: rW
OFFICE
r'