24477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY <
CITY OFCUPERTINO BUILDING-ELECI RICA], PERMI'TNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL TI24477
BUILDING DIVISION BUILDING PROJECT IDENFICATION
Buil.�IN�YG ADD0.FSSP SANITARY NO. APPLICA'T'ION SUBMITTAL DATE.
VJIO \ �� UNIT# LOl'p
ERNAME: 10 E _ CIJN'OtA( WSS NNAeliA _ LIC NO: WC CONTROL#
Z-27r� ARCHITECTIENGINHER: LIC NO: AID vI�/�I/�_ll3f: �` Vnky_ 1:9n ❑
CONTACT: PHONE: QTY. \1 ELECTRIC PERMIT IEE BUILDING PERMIT INFO
BLDG LILECT PLUMB MECH
PERMIT ISSUANCE ❑ E] 0 HCl.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
L�
❑y.Z IhembyaffDiisiol 3 of the
licensed provisifesions Coe,9nd(commencing with
4x100 Section]WO)of Dlvirinn3of the Business.nJ Professions Code,and my license is in PANELS
1- full tome and elf �-T 1
<" Licens Cla. - Lou#. Y UP T0200 AMPS
.I-<tor
a. Uam Conwcmr — 201-IOW AMPS ccnn,, IpIR2IEF�pn
ZOr`v'i•7a ARCHITECTS DECLARATION OVER 10(IIlAMPS / ®CORS Y -It
$ISQ.FT.
OZ-❑ I understand my,lans shall be used as public rcconb. 1..�
5G, Licensed Professional
OWNER-0UILDERDE DECLARATION SPECIAL CIRCUIT/MISC.
X06F0F I heathy n.irm(Se that 1 nm exempt from the CnnionsCe l License Law for the
F4Ot¢n whichfollowing"dresn($ection]031.5,onstrut,ader,imprve,drmAih,le:Any city or county TEMP.METER OR POLE INST.
rnJ which requites a permit to construct,elmq improve,demolish,Or repair any structure DAT D _
i� prior to its issuance.also requires the applicant forsuch Ini 1.Glee signed sedcmem POWER DEVICES
00 that he is licensed pursuann00aprovisionsoftha Contractor's License Law(Chapter
dX��' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
VALUATION
,M,, or that he is exempuherefrom wdlhe basis far Nealleged exemption.Any violatiori
tZa
Section 7031.5 by any applicant for a permapplicant it subjects the applicano o civil penalty of OUTLETS-SWITCHPS-FIXTURES
y❑
t more Nan five hundred doll...($500). NEW 0.1'SIDENTIAL ELECTR _SQ.FT.
❑ I.asche wrk,andeestrucy,mmyempeadediarofwed fors Ne(Sec.c0mpensi iess STORIES TYPE CONSTRUCTION
will do ares. rs Ca the he Comisnminmicense afw doe.ma up,[,
an came,
of
and Professions Cale:The Comrectm's License Law doh not apply to wt owner of
own ertywyees,pdvidedthatsun imprvndwhodocs suchmaint workhimffiredthroughhis OCC.GROUP RES.UNITS
own employees,prri,,nithatsuehimpviold oarcnotimmndedaroffered fors.le.If.
harder r.will have
orders of entivir,do,he did ma hard of complve faron,rhe owneo- TO'T'AL:
builder will have rhe burden of proving Ihm he did Icor build m improve for purpose of
ale.).
❑ I,us owneroftbe property,emexclmivelycontrectingwithlicensed conuanonm QTY. PLUMBING PERMIT FEE FLOOD LONE APN
construct the projcet(See.7044,Business and Professions Code:)The Contractors
License ldwdoesmm�pplym anownenofpropenywho buildsmimprovesthercon,and PERMIT ISSUANCE
whocommms for such Projects with acontrctuds)licensed pursuant to the Conbacmr's ALTER FEE SUMMARY
License Law. WATER(EA)
❑ 1 um exempt under Sea ,B&P C for this rcamn BACK FLOW PROTECT.DEVICE OUTSIDE-FEES
SANITARY YN
Owner Dat° DRAINSFl.00R,ROOF,AREA,COND. RECEIPTp
-
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
hereby affirm that I have a mrrfome of consent to self-marm,or a certificate of RECEIPT#
WONsr:C pcnsntion ons FIXTURES-PER TRAP
lnwmrv<oramnifiedcopy lhereof(Sm.3800.Lab C.)which PARKIEE YN
covers all grmW * rd p , GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPOp
Policy#__ ` _. BUILDINGRECFUIONFEER
Company l�T-- s TTn�— GAS-FA.SYSTEM-OVFR4(F.A) PLANCHECK FEE
s�0 CeniflcdcopyishcmbyfumishW.
y Certified copy is BI<d with the city inspection division. GREASEANDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thi,sectionneed not be completed ifthe permit is for one hundred Jollars($I00) SEWER.SANITARY-STORM EA.2001T. ENERGY FEE
or less.)
I cenify that i n the performance mf the work for which this permit is issued,l shall WATER HEATER W/VENTIELECTR
not employ any person in any manner sec as to become subject to the Workers' PAID
O z Comon Laws of Culifomia. Date WATER SYS'IEM(fREATIN4 Dam Receipt#
Applicant
icant
z Q NOTICE TO APPLICAMI'.If,after making this Certificate of Exemption.you should NEW RFSIDP.NTIAL PLMB. SQ.FT. TOTAL:
V] become subject o the Wmkds Compensation provisions ofihe Labor Code.you must
5 fmthwilh comply with such provisions moil,pemtit shall he deemed revoked. BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that hem is a concoction lending agency for the performance of
V O the work for which this permit is issued(See,3097,Civ.C.) _ TOTAL: ELECTRIC FEE
Lenders Name p PLUMBING FEE U Lender's Address QTY. MECHANICAL PERMIT FEE
1 cenify Not 1 have mad this application and statethatthe shove information arming
is MECHANICAL FEE aa^�
•�" Ctn mtrect.lugreeto ction, 1 wird allcity and mm�tyordinanaaandstate lower upongto PERMIT ISSUANCE U' Z huildingcoasied!pr,and far inspection
rcprcuntativesoflhiscirytoenteruponthe
V z above-mentioned property for inspection cs. ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We)agree to save,indemnify end k,cpkeep thhamsters the City o Cupeninn against
rou
liabilities,judgmcs,cnsand<xpenux which may ineny way accrveageinst said City AIR HANDLING UNIT(TO Io,O(1O CFM)
ce of the mtingo thisp noir.
AIR HANDLING UNIT(OVER 10,0110 CFM)
rig
Vary
of Applican(Cmttrecmr EXHAUST ROOD OVIDUCT)
PAID
IIAZARDOUSMATF.RIALS CLOSURE HEATWG UNIT(TO 100,000 BI'li) W Date Ri t#
Will the applicant or farm huilding occupant staticor handle hazardous material
as defned by the Cupertino Municipal Cade,Coupler 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T 1:
Code,Section 11532pd? VFN
❑Yes CI Na TMTION FAN(SINGLE.RPSID)
Will thenpplicantarfmurcbuildingocenpant uueyuipmentordevicea whichemit
BOILER-COMP(3HP OR I X),(100 BTU) ISSUANCE DATE
hazardous air contantiwnls as defined by the Bay Arcs Air Quality Manapticid BOILER-COMP(OVER 100,000 BTU)
) p
El Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Ys�
I have mud the hazardous materials requirements under Chapter 6.95 of the I�tl� eco{] oil
California Health&Safety Cade,Sections 25505,23533 and 25534.1 understand Halt
ifthe building does nor currently have amount,et it mysuanceiofa to notify the
occupant of the requirements which must be met poor m issuance of a Certificate M
Owner.,y. —✓_ I
Owner or umhnrizoJ.gent Dam TOTAL: ISSUI3D BY:
OFFICE