24793 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE RICAL PFRMITNO.
APPLICATION/PERMIT PLUMIIING-MECIIANIC,A[,
BBUILDING DIVISION BULL.DING PROJECTIDENI'IFICA'f1ON LA
I
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
So S D UNIT# LOT#
OWNF NAME PHONE: 6. CONTRALUMS NAME: LIC NO: 1
O 1'1 NIC CONTROL is
ARCHITE T/LN it L : LIC NO DHPSS: w
IG ❑
bD fthl.4
CONTACT: PHONE:
/�7/�/ /�/� _�8 (J QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
• 'rn�" ,~ le)Q—, �����/� PERMIT ISSUANCE EI-F.CT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTIONtY 7 1 hereby affirm that I um licensed undcrprovisions of Chapler9(commencing with
Section 7(01)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
fall
Lic.# UPO20
e Commetor xZMAJAS
<Zy) Licensee�Jaln�d effeol� ry� TAMPS
nFs6N DaL
Fy ARCHITECfSDECLARATION SQ.FT.FLOOR AREA f/SQ.ET.
ZOrn3 OVER ELL AMPS
C Z— 1 understanA my plans shall Be used as public records.
(.,y 1� SIGNS ELECTRICAL
g Licensed Professional
❑� OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOfl.U I hereby affirm Net I am exempt from the Committees Licetre Ina routine
W 3 4 vFi following reason.(Section 7831.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
�RJ�g which matures a Permit o construct,alter,improve,demolish.or repair any swctum
oc Y� prior.its issmare.lsurtauinesta
happlic. um nt far such pnnfile.signedstmemmePOWER DEVICES
µ�j npa that he is licensed pursuant to the provisions ofthe Contmetor's License Law(Chapter
d eLL 9(commencing with Section]OfM1l of DivixionJof the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
yxf�y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Of1TLET5-SWITCIIFS-PIXTURGS
.Z.Q Station 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
n......him five hundred dollars Send). .
K❑jp ElI,asowneraftheproWny,ormyemploymswithwagcsm Neirsolecomp nsatiNEW RESIDEMflA1.ELELTR SFT.on, _SQ.FT. TYPECONSTRUCTION
6 willdo the work,and the attraction,is not intended orofPomd forsale(Sea]044,Bminess
and Professions Care:The Comtactora License Law does not apply to an owner of
par eny who mildsor improves thcrcon,andwhodoes such work himselfnr Nrouglt his
employees,pmvided that such improvementsarcrm mandedmifferat Tarsale.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one ycarofcompletion,the owner.
builder will have the burden of that he did not build or improve for se ofsublTOTAL:
provin8 P Para'
e.).
[3I,us nwnernfthepropeny,.mexelusivelyconlracting wiNlicensed camracmram QTY. PLUMBING PERMIT FEEFlOOO ZONE APN
construct the project(Sec.70a4,Business and Rofessmas Code)The Counselor's
License Lowdrus not apply manownerofpropeny who buildsor improves thereon,end PERMIT ISSUANCE
Whocontrecr for such projena with a Contractors licenced pursuant to the Contractors ALTER (FA)
Licere Law. FEE SUMMARY
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY 0 Y TFff5L � N
Owner Data DRAINS�FLOOR,ROOF,AREA,GOND, RFCLIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby aflimt that l have a certifcamofcousem toself-acure,ora cerificateof FIXTURES-PER TRAP RECEIPTN
Worlers'Campeassion lnsuranceor a certified copy thereof(See.3800,Isb C.)which PARK FIFE Y N
coven allem tler this permit �[',o
GAS-I3A.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy. BUILDING DIVISION FEES
Company Z�Mi OA/ i`w_.
❑ Cerifiedca � GAS-EATIiHE.$Y$ MOVER4(EA) PLANCIIECK E
py is hereby fumrahed.
❑ CertifieJ copy is fled wi@the city inspection division GRFASEANDUSTRI.WASTE INTERCEPTOR GRAVING FEE
CHRTIFTCAT E OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not bccampheard ifthe permit is fir me hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FP. ENERGY ME
orless.)
I verify that in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any Person in any manner so ss to become subject at the WorkersPAID
Compensation Litwsof California, Ilam WATER SYSTEMA REAPING Date RmeiPtq
� 2 NOTICE TO APPLICANT:If,after making this Certificate of Excitation, hould NEW RESIDENTIAL PI.MB. SQ.IT.
'z '.. g You s TOTAL:
F-' > hews Ida
coecly with
Work era Compensation provision of be he Labor Craft,you must
� > foMwith comply with such provisions or this permit shall bcdomed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby.aft trot that there is u construction lending agency far the Ni-fnmance of
U 0 the work far which this Permit is issued(Sce.3897,Civ.C.) TOTAL: ELF,CfRIC FEE
Ixrdre.Name
OLenders Address QTY. MECITANICALPERMIT FEE PLUMBING FEE
U T certify that 1 have mad this application and state that the above information is
r7" LTJ toren.Iagree to comply with all city and county ordinances and sum laws relating to PERMIT ISSUANCE MECHANICAL FEE
rF-r building construction,andherehy,awhotire representatives.Rhos city menerupnnthe
U above-memitared property for inspection purposes. At,'[LR OR ADD TO IsLCI I. CONSTRUCfIONTAX
(Wo)agree to save,indemnify and keep bumless the City of Cupcnino against
Iiabilitin,juJgmrnts,costs andapcnus which meyinnny way accmea ainst..id City AIR HANDLING UNIT(TO I0yMBCFM)
consequence of the granting of tpermit. AIR IIANDLWG UNIT(OVER 18,000 CFM)
Signature of A,j5P0CcmVact1 Dice EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]'r(TO loo,"BTU) Date Receipt#
Will the appliwm or furore building occupsom,a re or handle hvsrdous mmerinl
its defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10(1,000 BTU)
Code,Section 25532(ep
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DAT
Will the applicam orfmure huilAing nccupem useeyuipmem ardevicen whichemit
haaerd0.1 air conmminnnts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Ism � O
District?
❑Yea ❑No NEW RESIDENTIAL.MECH. SQ.FT. RIqq
ID
1 have real the h.ssrdon materials requircmenu under Chapter 6.95 of the APR 2 8 ,g
California Death&Safety Code,Sections 25505,25533 and 25534.P understand that
if the holding drea rut curemly have a roam,that h is my responsibility m entity the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Ownef or umhndzcd agem Data TOTAL: ISSUED BY:
OFFICE