24748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-KLEUI RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24748�1 O
HULLOING I3IV ISIf1N BUILDING PROTECT IDENTIFICATION L� 4 o
BUILDING ADDRESS: SANITARY NO. APPLICA'EON SUBMi'ITAI.DATE
I
i 104( PQ0WeJRk F,l1NIT# LOT# �S
OWNEIjyNAS� I PHONE; CO CI'0 :S AME:
�`T// \ �'ON/F CONIROLM
• AItCHI'fF,Cf/F:NOINPER: LIC NO: ADDRI? N Y
SO(o- P6L_I. VG 0c.4
CONTACT- rn 1-PE: _O1C QTY. ELECTRIC PERMIT' FEB; BUILDING PERMIT INFO
vmwy .'(b' LDO III ECT PLUMB M
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIALnwz BOB DESCRIPTION
W,00 Thereby ofrmthml 3 of
he Business ndPrfesioCh ode,and mmecence with �I
p100 Section]BIXQ of Division J of the Business end Professions Code,and my license is in PANELS
yzw full fort nd eflbc .11'1'0 A, UP T0200 AMPS
��m Lic1C CI^s Contractor rO '1 201-Iqp AMPS
ZOy ARCHITECTS DECLARATION OVER LOGO AMPS SQ.FT.Fl"00 EA 'Q.FL
O Z^ 1 understand my plans shall be used az public taoNs. A L E
Fy i SIGNS ELECTRICAL
aaid Licensed Professional f� /7
�J9P OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. I I,\/' T E
ip(,OaF 1 hereby affirm In.,I am exempt loom the Cmmnvcmex License Law for the Y V )
m9n.m following mnson.(Sedion]OJLS,Business and Professions CtNe:Any city or county TRAIRMITERORPOLEINST.
O5 which requires u permit to conxtmct,vheo improve,demolish,nr repair any nmaure C {/
sp �M prior to its issuance,also requires the applicant for such permit to rile a signed statement POWER DEVICES D G _
yl^q that he is licensed p irsuanno the provisions of the Committees License Law(Chapter
a'Ke '9(commencing with Section 7000)of DivisionJofthe Business end Pmfessimc;Comic) SWIMMING POOL ELECTRIC /� VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violationuf Uqq mss-SWITCHES-FIXTVRfS / /
tZG Section]031.5 byanyapplicentfor.permit subjects theepplicanuoaciviE RneltY of V �7
not mom than rive hundred dollvns(E5IX0. NBW RESIDENTIAL ELECfR 3 .FR.
C ❑ I,mownerofNeproperry,nrmyemployceswith wages mstheirsoleconTemation, Q 'TORIES 'TYPE CONS'IRUCUON
M
wi 11 du the work.and tlm structure is not intended or offered for sale(Sec. Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who bui Ids or i mproves thereon,and who does such work himse I f or throu gh his
employees,providedthatsuchimprovemcntsurenotintendedoroffere(iforsale.If, OCC.GROUP RES.UNITS
however,the buddingor improvement is sold within one yearof completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of L'
talc.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ l,mconstruct
rject(Sroperty,vmexdusivelycontfessio wirdde:) he Contractors
conswm the wdoes not(Sec.oano Business and Professions crimp The Cersor,ar's PERMIT ISSUANCE
License l.awdocs such
apply toenoh mcontproperty whobuildsorimproves thereon,and
whence Law. ALTER
suchprojecbwithacommcmr(s)licensedpurtuentmthe Comrecmh ALTER-DRAIN&VENT-WATER IPA)
License I.aw. FEE SUMMARY
❑ 1 nn exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE f TSID. .E
SANITARY YN_
Owner Date RECEIPT#
DRAINS-FLOOR,BOOP,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCI1001.TAX YN
❑ Ibercby offrmthmlbaveucenificateofconsenttoself-insure,nramrdficateo( RECEIPT'#
WmkerR Com copy FIXTURES-PI:R TRAP
peneationlnsuana orvicenificd co thercof(SaJA00,Lab which PARK IrF.E Y
covers
all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUT'LET'S RECEIPT It
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE s Sj
❑ Certified copy is hereby famished.
❑ CenifieJ copy is flet with @eeiry impenion division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FRE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE /�
Thisscetion need nm bccme p
npleted ifthermit is Forane hundred hund dollars(EI110) SEWER-SANITARY-STORM EA.200Ff. ENERGY FRE 462 00
s.)
I ceoy a oat inthep in anyanmof the so us for becomech hsubject to the W,lshallkem' WATER HEATER WNENTRiLF.CIR
not employ any Iverson a any manner so us m become subject m the Worker' PAID 37? $S
Z Compensation w
Lan o(CalifomieSTG
. Date WATER SYM(fREATING Date Receipt#
Applicant
C 4 NOTICE bj APPLICANT:Worker's
atannnsati this Cisions sof Ludsor ion,yous am&, NP.W RESIDENTIAL PLMB. SQ.FT. TOTAL:
1-" to become subject to Workers Campcnsmitm provisions of the labor Code,you run
a ; forthwith comply with such provisions or This lamitshall be deemed revoked. BUILDING HE
as Q CONSTRUCTION LENDING AGENCY SEISMIC FEE �y/� J_r, p2
.: z I hereby affimr that here is u casamction lending agency for the performance of
Ur CTRIC —�the work for which this permit is issued(Sec.309],Civ.C.) TOTAL: ELEFGE Lender's Name
0 U Lender's Address QTY, MECHANICAL PERMIT FEB? PLUMBING FEE
1 certify that 1 have rend this application and rate that the above information is MECHANICAL FEE
correct. lagrceme�mply with tall city and county oNinnnew and state Wwereleting to PERMIT'ISSUANCE
building construction,and hereby nuNnriu repmseninives ofthis city to enter upon te
hCONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep brmaless the City of Cupertino against
liabilmes,judgmena,cmts andeapeaiv,which may in any way atrneagainsuaid City AIR HANDLING UNIT ITO 10.000 CFM)
ns qu ace of the gran' gal this permit.
3-3,0-93
^�O— AIR HANDLING UNIT(OVER I o(am CFM)
Si aareof Applicunt/Contnmror •7 Date VAHAUSTHOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Uate Rtteipt#
Willthe applicant or future building occupantmore or handle hananlous mmeriul BEATING UNIT(OVER 1(p,IXp DTII) TOTAL:
as dallied by the Contends.enis.Municipal Cale.Chapter 9.12, the Health and Safety
Coda,Section 25532(a7]
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Wilhhe appliwnmrfmurebuilding occupnnmseequipmemonleviaswhich emit
BOILER-COMP(3HP OR I00,000 BTU) ISSUANCE DATE
srdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 Ent
_11mcl'1
❑Yes 0 N NEW RESIDENTIALMECII. SQ.Fp. Pf p I D
I have rend the huaardaus materials requirements under Chapter 6.95 of the li /sY
California lieahh&Safety Cole.Sections 25505,25533 and 25534. I mnde..and that �� O
if the building does not mentacurrently have a sabot,that it is my responsibility to notify the 19a
Ococcupant of the requirements which must be met prior m issuance of a Certificate of y
cup;mncy.
Clad rU
Owner or awhorieed at Data TO AI: ISSUL'D Y:
OFFICE