24829 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x n•Dwr..ELECTRICAL PERMITNO. r� n
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROAEC2 4 p L J
I IDENTIFICATION G OO L J
BUILDINGADDRFSS: `- SANITARY NO. APPLHIVIII IONIUBBM///I'ITAL DATE
2164"1 �`+`�w ' UNIT# IATA
' OWNERS NAME: ��� PHONE: CONTRAu;R';NAME: ar
LIC NO:am N/C CONTROL#
ARCHITECI'/ENGINEER: LIC NO: ADDRESS:
E RD .Se
CONTACT: PHONE:
A QTY. ELECTRIC PERMIT FET; BUILDING PERMIT INFO
V�Ngy ��� �v� I � PERMIT ISSUANCE D PLUME CI
LICENSED CONTRACTOR'S DECIARATION APPLIANCES-RE.SIDEM'IAL OB DESCRIPTION
p y.2 I hereby affirm that l am licensedunder provisionsofChapter9(commencing with
PVOO Section 70M)of Division Sof the nosiness d ProfeesionsCJq and my license is in PANELS sl�k�
{{�W full force and ercec, \)IG/►
<?aw License Cl... Lie.p 53'14A4 UP TO 200 AMPS lV
xo<o. Dmn Convenor 201-1000 AMPS
F-o,Z ARCHITECT'S DECLARATION SQ.FT.PLOOR $/SQ.FI'.
ZOv'— IundcmlanA my Pbtre shall M1c used as 11' Ns OVIiRimXl S
OZ—O Pr++.c recd .
FyFa SIGNS ELIC IC L
94yyy W Licensed Professional
S < OWNER-BUILDER DECLARATION SPECIAL Cl C I' IS . P FR
k0sL U I hereby affirm that I un exempt from the Contractor's License Uw for the
{y31iy following reason.(Section 703 1.5,Bnsinessand Profesvions Code:Any city or county TEMP.METER OR POLE INST.
f=LLOj which requires it permit to cm,truct alter.improve,demolish,or repair any umeture CI
primo its is,mm,,alsorequireathe applicant for such peanut fileasigned statement POWEt DIiVI
thm he is licensed p...tomr m QaToovisinnsnf the Commerce,License Law(Chapmr SWIMMING POOL ELEC'T'RIC
aa�LL 9(commcncing with Section 7")of Division 3of+he Isminessand Professions Cartel a^yA/I�y{7A
aaaaa
y or that he is exemprtherefrom and the basis for the alleged exemption.Any violationof O OUTLETS-SWITCHES-FIXTURES s J "JI
�/�
,Za Section 7031.5 by m,ti,licant lorape.il,nhj,cts thett,l icxnnn a civil penalty of C/
not more than five hundred dollen($500). .
Wp ❑ T,nxnwnendthe pn+pedy,nrmycmPloyecswith wagesnOhcirsnlecompensatlon, NEW RESIDEMI'IAL ELECIR —SQ.ITS'T'ORIES TYPE CONSTRUCTION
L will tlothewons end the no
Contractor's
int License
Law
does not apply
to an owner of and Professions Cade:The Commcmr'a License Law does not app1Y m an owner of
property whobuilds or lmprovesihereou,andwhodocasuch work himselfor through Is OCC.GROUP RES.UNITS
rownernployees,Provided that such improvements ore not i ntendedor offcrd far a de.If,
however,the building or improvement is sold within one yuuofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
tole.).
❑ I,us nwnersdNe Properly.um exclusively emarnming with licensed contractors to QTY. PLUMBING PERMIT FEEFLOODZONE APN
constructive project(Sec.7044,Business and Professions Cde:)'ILe Conwetor's PERMIT ISSUANCE
License Lawdoesnot apply to an ownerof propenywhn builds or improves thereamand
whowmmets for such projects with a conamesup)licensed pumuantto the Gmtraclors ALTP.R-ISRAIN& - 1'P (I
License Law. 1A) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this anconBACK FLOW PR(Kc. tiE
SANITARY YN
Owner Data RECF.IITp
WORK MAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AR. ND. SCHOOL TAX Y N
1 hereby affirm that 1 have a certificate of consentlo self-insum,or a cedificaa of RE'CEIP'T#
Wmkerd Com R URPS-PF.R'fRAP
pensminmale,tanceoracenifiea copy thereo((Sec.l800,Lab CJ which PARK FEE V N
covers all employee's under this permit GAS-P. Y$TEM- ITLP.TS RECGI
PolicyN BUILDING DIVISI NFITFS
Com any GAS-FA.SYS 'M-OV17R4(EA PLANCHECK FER
nified copy is hereby fumishes�. Iq"j�
Certified copy is filed wish the citym tai Gk1iASE/INDUSIRL STF.1 GRAVING FF.F. �e
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifrhe Permit is foronc hundred dollars(SHlb) SEWER-SANITARY-S'T'ORM EA. 7 I, ENERGY FEE
ar less.)
T cenifythutln the perfnm+uncenfthe work fxrwhich this permit is issued,Ishull WATER HEATER W/VENT/T1.IiCfR
not employ any perom in any manner so es m became subject to the Workers PAID
Z
Applicant m Comperaramolut—mf CelifomiaB
. Date WATER SYSTEM/ EATING Receipt#
0 0 NOTTCIi TOAI'PLICANT:IfaRermakingthis Certificaaof F.xemption,youshould NM
EWRESIDE 'IALPLMB. SQ.FT. TOTAL:
i/3 Mcnmembject tothe Worker'sisionsrhis pmvisions1 beeened Caday. man
7 fnnhwiib comply with such provisions or his pcmtil shall be deemd revoked. BUI G +E r1 �..
GQ CONSTRUCTION LENDING AGENCY ZSMIC ;E Gr
z 1 hereby affirm that them is a construction lending agency for the peRarmarrce of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
QU Lenders Address QTY. MECHANICALPERMIT it—
HAMRDOUS
I certify that I have read this application and store that the above intonation is
correct.l agree m comply with all city and county ordinances and state law srelutingto PIEMI'I'ISSUANCE
I"' N building construction,and hereby authorize representatives ofthis city to enteruponthe -
V Z above-mentioned propsny for inspection purposes. ALTER OR ADD 10 MECH.
(We)agae to save,intlemnify end kap hmmlas Ne City of Cupcnino a eine
Iiuhilities.judgments,costs and expenseswhich may in any way accrue n Ciry AIR HANDLING UNIT CIO I0,00d)CPM)
incumse e of the granting of this permit.
AIR HANDLING UNH'(OVER TO."CFM)
nmum of ApplicanOCnmmctor Dm EXHAUST HOOD(WA)UC)
OUS MATERIALS DISCLOSURE HEATING UNIT(TO 1(111,000 BTU) ptat
Will the applicant per future building monist stupe or handle hasabous material
as defined by the Cupertino Municipal Code,Chapter 9.12,motor l leahh and S.afgy I BEATING UNIT(OVER I OQO(p BIG) OPAL:
Cde,Section 25532(n)9
El Yes ❑No VENTILATION FAN(SINGLE RESID) N IFS Ur I
p,fictual
Wiis tair contaminants
orPomm building by the
equipment Quality
Management it
BOILER-COMP(3HP OR I W.000 ITT U) ISSUAN •DATE
.hazatdmis air consaminann as defined by the Bny Area Air Quality Management BOILER-COMP(OVER I00,0fH1 BTU)
1 Uisvieft pPo
❑Yes ❑No NEW RESIDPNTIAL MECH.—SQ.FT P A B
1 have reel the hauNoos materials requirements under Chapter 6.95 of the
iftheuil HcaRh&Sofcry Crde,Seniors25505,25533and ye,ma. understood that OFN'I se��
ifthebuildingdoes mm�cemix yhaventonne,that it is to utitmesiofa in notify the
occupant of the aquirementa which must h met prim to ix uence of a Cenificme of
Oceupnney. C
tt
Ownerorauthodud agent Dere i` ISSUED BY:
OFFICE