24586 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBL ILDING-ELK'DUCAL PHRMII'NO
APPLICATION/PERMIT PLUMBING-MECHANICAL �I C O
BUILUIN.DIVISION BUILDING PBOJEC'IADENTIEICATION 4 J o
I{IIILUI/O NG31aiSS: SANI9'ARY NO. APPLICATION SUBMI'MAL DA'II:� / Oar/ lHr"— UNI'fp LOTp
OWNI: Sy E: �DONE IPis3 6 COSTS C4.e5 R M // l� LIC NO.
f N/C CONTROLp
CIIITECI'/C:NGINEER: LIC NO: AD RESS:� �5 T� �❑
:ONTACT: PHONE: S QTY. BLfiCTRIC PERMIT B F
tRMI'1' PCJIBUILDING PERMIT INFO
BLDG ELECT PLUMB MGCII
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 100 DESCRIPTION
pyZ Ihereby of am that l amlicertttd underprovisimis mChapacti)mmmncncingwith
FJOC) Section 9000)of Division 3ofthe Business and Professions Code,and my license is in PANELS `
ym full forte anile ns.�G7S UPT0200AMPS
< f.umc Class -'�6 1 ek
Lica e! 1
may Dam •- Convertor 201-10(11)AMPS
ZOyZ ARCHITECPS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA I;/SQIT.
CZ-0 Iinderstandntyplans skull be used.,pvhliencoads.
r y t tel SIGNS ELECTRICAL.
$ Licensed poire slomtl p n
"ICU OWNERBUILDERDECLARATION SPECIAL CIRCUEOMISC. I 4 II ® A ■
iyyi��O W U I hereby affirm than I um exempt from the Commetors License law for the 'I N
ut'+pm following reason(Section]031.5,Business and Professions Code:Any city or county TEMP.MEER OR POLE INST. ` �.. ;N
1"OS,n; which requires a permit to consumer,slant,improve,demolish,or repair any structure 1 r,� �I 1� •�I I'
� Y•� prior to its issuance.olso pauiresthe applicant fonuch permit file asigned stemma., POWER DEVICES a l�l u (�
W n,'D O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
y 9fcommencin ith Section]OW fUivision3ollhe llusinesv and lkmfcswinns CnJe SWIMMING POOL ELECTRIC
Xo� Bw )o ) LIJATIO�
orthat 1031. by
refromand the Basis for subjects
Wealicant n.Any I penaun of OLGLETS-SWITCHES-FIXTURES
FZ_a net. ]031.56e hundred
dollrm$500).tsrbjccts the applicammacivil penally of
pnot more thea five hundred dollars(5500). NEW RESIDENTIAL.ELECIR _50.14.
❑ I,fleavocrof he rk,anheestructy,ormyemteadeswitM1wugosnsale(Snlewngnnsutinn, STORIES 9TPI?CONSTRUCDON
L will do ftsaimk,amd ch he Contrature is tot is License
Use
s not apply rel an Business
and arty whamrs ldsor The Contractor's License l.uw docs or apply to an owner of
propertywho,s,Idstari.,proves hereon,and whodmnsuchworkhi.,seller throughhie
employees,pnwidttlthm such improvemcrosvre not intendedurnffered Tarsale.If. OCC,GROUP RES.UNH:S
however,he buildingor improvement is sold within one year of completion the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lao mwnerr,Uh"nopeny,ame,cwsively, contracting with ticenssdcontrectors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
ondract the project(Sec.7044,Business unit Professions Code)The Cmnvoam's
Licensew Jce
Loa n o rt,l......erof propedy who hinds m PERMIT ISSUANCE improves thereon.and Sz�
who contracts for such projects with it contractor(s)licensed masseur to the Cmnmctm's pL'1'ER-DRAIN&VENT-WATER(RA)
License Lew. PEI:SUMMARY
❑ I am comp,under Scc. ,B&P C for this reason BACK PLOW PROTECT.DEVICE SANITARY TY DE FRES N
Owner Dam DRAINS-FLOOR,RODE,AREA,COND. RECEIPI'p
WORKMAN COMPENSATION DECLARATION SCIIOOL 9'A% YN
❑ IM1ertM1y afOnn thmlhaveacenificate of consemmulf-Insure.ora eenificum of FIXTURES PER TRAP RECEUTp
Workers'Compeynnsattiioltn Insurance or a rectified copy thercof(Sce.3900,Lab C.)Much PARK FEL: Y_Ncovers _
palmy M 1��yc r27hCJ^Y� RDIVISI'q
GAS-EA.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FRES
Company ---�--- GAS-EA.SYSTEM"OVER 4(EA) PLANCHGCK FEE
p❑ Cenilled copy is hereby famished,
T Certified copy is fled with the city inspection division. GRFASFgNDUSTRL WASTE JIMHRCHPTOR GRADING FEE
CI'eRTIPICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section rend not is,completed ifthe permit is forma,hundred dollars($100) SEWER-SANITARY-STORM HA.200FT, ENERGY FEE
or less.) `
I certil'ytha,in the perfnrvamceof the work for which this peramUs issued.Ishall WATER II EATER W?VEN"I'/fiLHCfR esv
not employ any persmn in any manner so as m become subject,o the Workers' PAID
z Compcnsation Lawsof Calilornia. Date WATER SYSTENVIREATING Dam Receipt a
Applicant
z0 NOTICE S'0APPLICAN'C ILuReruadinEldd,Certificate or Eaemptimn,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
0, bccomesubjcam,M1e Wei Compensation provisions.,fine Labor Cock,you must
forthwith comply with such provisions or this pemsit shall be deemed revoked. BUILDING FEE
W CONSTRUCT ION LENDING AGENCY SEISMIC ME
z
^� I hereby offimt dauditre iso construction lendingagemcy forth,plabounance of ^^ .Sv
V O the work for which this permit is issued(Sec.309],Civ.CJ TOTAL: d� ELECTRIC FEE
lender's NamePLUMBING PEI? p
0 U laudcrs Address QTY. . MECHANICAL PERMIT FEE aKt�
I verily Iha,I have read this application and elute that Lha above infonnadon is
coned.I agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICALFEE
�-' huilding construction.and hereby umherize representatives of this city to enter upon the CONS]RUCTION TAX
V Z above"mentioned property for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitles,judgments.arsts andeapcnaes which may many way.ecrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
11 tt mequence or egrnming of,his permit.
AIR HANDLING UNIT(OVER 10.000 CPM)
ra,ureof ApplicarolUmuuctor Date EXHAUS'PIIOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE I[EATING ONE"P(TO 100,000 BTU) Dam Receipt If
Will the applicant or future building occupant store or handle h izallous material �qq
as defined by the Cupenlno Municipal Cale,Chapter 9.12,and the Ilwlth and Safety IIRATING UNIT(OVER 100,000 BTU) TOTAL: �aL•s�
Code.Section 25532(a)?
❑Yes ❑No VEN ILA-11ON PAN(SINGLE RESIDE
Will lhe sit co icumor ,es a.huilding by the nBay A uipmcnmuality es Mw.Eleme it
BOILER-COMP DHP OR 100,WO BTU) ISSUANCE DATE
hazeNotu air nmtaminane os definW by the Bey Area Air Quality Management
District? BOILER-COMP(OVER 100,000 RTU)
❑Yea ❑No NEW RESIDENTIAL MECII. SQ.FT. g� B
I have rend the hazard..,materials requirements order Chapter 6.95 of,he V'
California Ilea di&Safety Code,Sections 25505.21533 and 25534. L understand that FEB
cOmparm orhecsmmcurem lybevcatenan anctsulsmyr...nee iof.Cernficat the L ,
occupant or he mquimmenD which mus,be me,prior,o issuance of a Certificate of y J
Oavpancy. •I
Owner mamhori,edagcm Dam TOTAL: ISSUED BY: T • r aUrtl'II II4f1
OFFICE