24911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CI'PYOFCUPERTINO BIILI! G-ELF.CIRI AI, PERMITNO.
APPLICATION/PERMIT PING MECHANICAL
ENTIFICA 2 ^ 911
BUILDING UIV1910N IfUIL01NC.PROJN:CT IDEN'TIPICA'TWN Lf'F
BUILDING ADDRESS SANITARY
SANITARY NO. APPLICATIONSUBMITTALDATE
ell / / yUNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
• 'T� • r N/C CONTROL M NARCI IT �
T : ADDRESS:
❑
CONTACT: PHONE: v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
��9J Y ELECT PLUMB MECH
PERMIT ISSUANCE
_
LICENSED CONTRACTOR'SDECW ATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
p4'z I herebynffrm that lamlicenxd under maxisionsofChepter9(commencingwith
Lil W O❑ Section 7000)ofDivision 3 of the Business and Professions Code,and my license is in PANELS
F zw License e-ss �� Lic.# , EJ� UI"1'0200AMPS
H=y Orae Contmdpr J -Gf4Y✓.f 1 201.1000 AMPS (••/J /�
,z O,zoi— ARCHITECTS D: + OVER]"AMP5 t SQ.FT.FLOOR AREA E/SQ.FT.
O'Z—0 I understand my plans shall be used as public retards.
I r4�oj SIGNS F.LECI'RICAL 1 ! I� ! \ \ D II II V
Q W„rj Licensed Professional OWNER-BUILDER DECLARATION SPRCIAL CIRCUIT/MISE
x4px'OLGF 1 hereby affirm that I hat exempt from the Connanors License Lew,for the l II I l �
W3..34mQ following imers,(Smticar7031.5,Business and Professions Code:Any ckyorcoumy TEMP.METER OR POLE INST.
C LL105 which requires a permit m cott,omel,alter,improve,demolish,m repair any saucmre W
4A',oa� prior to its issuance,also requires the applicant lisrsuch p,mutto file a signed statement POWER DEVICES DATE V
w p O that he is licensed pursuant to the provisions of the Commcan.License law(Chap¢.
440 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W=y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of ,y
Fe- P Sen inn 7031.5 by any applicant for a permitnubjecrs the appno
lictoo civil penalty of OU'I'LRI'S-SWITCHES-FIX'fUREg may/ /ele)0, UO
2 0
out more than five hundred dollars(ESIID). NEW RFSIDIMIAL ELECTR S .FT. T'
K m CII,asmwneroftheprowM.ormyemployaswithwagesastheirsolemmN=lion, Q STORIES TYPECONSTRUCTION
yg_ will do he work,and thenrovare isnot inteodedmitffrmed fa aale(Sec.7144,Business
and professions Code:The Contractor's License Law does not apply to an owner of
property who builds nr improves thereon,end who rices such work himself m through his
employees.provide(ithat uchimpmvements=notitnendmlorofferedforsale.If. OCC.GROUP RES.UNITS
howeveq the building orimpromment is sold within one yearofcompledan,theovorm, TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sulc.).
❑ I,ns owner d'the property,um exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FP.F, I1,00D ZONli pl'N
construct the project(Sec.7014,Business and Profession Code:)The Connector's
License lawdas not apply tuanownerofpmpenywhobuilds mimpowes thereon,and PERMIT ISSUANCE
who contracts forsuch projects with a conuactorad licensed pursuant to the Connector's
LiamsoLaw. ALTER-GRAIN&VPNT-WATGR EA
) PBP.SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this.ammo BACK FLOW PROTECT.DEVICE ID
SANITARY Y N
Owner Doe RECEIPTp
• WORKMAN COMPENSATION DECLARATION URAINS-FLOOR,ROOF,AREA, SCHOOLTAX YN
all hereby affimt that I have o mnificnte of consem res st lf-in,me,or a cenifeam of RECEIPT#
Worker'Compensation Insurance or nifed copy flicmf(Sec.3800,Lab C,)which IJXTURLS-PFiN'fRAP PARK FEE Y N
covers aIle la e�y ytpe t 's RECEIPT#
Policy# �e�T GAS-EA.SYSTEM-I INC.401f1'LEfS
BUILDING DIVISION RES
Company f2g$ -per+ �-� OAS-HA.SYSTEM-OVER4 HA) PLANCHECK FEE
❑ C'cniticdmpyiahcmbyfmmshmL
[d,CenifM ropy is filed with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPT]ON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thia.mlinn omdnotbscumplctedifthepemdB fornnehundreddollars SINN SEWER-SANITARY-STORM FA.200FT, ENERGY FEE
or lera.)
I minify that in the performance f,he work for which this permit is issued,i shall WATER HEATER W/VENT/P,LECIR
nut employ any person in any manner ao ns to become subject In the Workers' PAID
Z Cmmpen.vatinnl.nwxnf Califomia. Date WATER SYST13MURMI'ING Mare Receiptp
Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Cent of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TA .
r Vj bacons subject n the Workers Compensation provisions of the labor Code,you mml
�. forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
nal. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz Ihereby affirm that here is a construction lending agency for the pc.formena of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ITE
P. LadcrsName
O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I cenify that I have mad this application and state that the above information is
F OWa coned.la to comply with all cit county g MECHANICAL FEE
gra pdhe yard count ordinances equiwe,ttlan to PERMIT ISSUANCE
y albovengmtioned property
horinspectoriurerova. ntives ofthiscirymemeruponthe CONSTRUCTIONTAX
U 7 abnv(We).,ed prnper indemnify and purposes. A1.9'I?R OR ADD T'O MF.CII.
'tom (We)agree nt save,indemnify and kap harmless the City of eagano s against
incommit rce of
the
expenuermit. my in any way acerveagairut said City AIR HANDLING UNIT QO 10,300 CFM)
consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I11,0N010 CIT4)
Signature of Applimm/Cmatmor Date EXHAUST HOOD(W/DUCq
PAM
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00.00d BTU) Data Raeila#
Will Me applicant or future building occupant store or fondle bamrdous material
as defined by the Cupertino—Municipal Cole,Chapter 9.12,and the Health and Safety I]RAPING UNIT(OVER I ORWOBTU) L:
Code.Semi 25572(u)?
0Yes l mllr/ VENTILATION PAN(SINGLE RESID)
W III the applicanror fmurc M1uilJing occnpmn use eyuipment nNeviccs which emit
BOILER-COMP(3HP OR 100,3X10 BTU) ISSUANCE DA E
• hazardous air contaminants as defined b eBay Arm Air Quakily Management
District? BOILER-COMP(OVER 100,000 BTU) P A I
13 Yet, NEW RESIDENTIAL MECH. SQ.FT. ��� _
1 have read the hmardous materials requnements under Chapter 6.95 of the • 1994
Californi Health&Safety Cale,Sections 25505,25533 and 25534. 1 understand that
ifthe d It does not currently have a boanL that it is my responsibility to notify the CIiY Ur GUrChEIIVU
Oce n
Z It t atsants which he ren issuance oG C�i sof
u0n/ l T
Ow cr or authonod agents one ITOTAL: ISSUED BY:
OFFICE —�7