24661 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1. INL. ..ECJ'RI AI. PERM]PNO.
APPLICATION/PERMIT PLUMBING-NIECHANICA I. 24661
BUILDING DIVISION BUILIII NG P JECITD TIF'ICAI ION
BUILDING ADDRESS:
O• \� � /� �� `
SANITARY 0. API'1.1�1JI1M1'1'1'AI,DAII!
UNITa NO:O03C6 7FlPb�
NNPHONE: C MLIC
X NIC CONTROLp
jpvtCHITEGI'/HN rINEER: LIC NO: ADDRESS: 0
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BI F,I.F._ P U M r
PERMIT ISSUANCE ��
LICENSED CONTRACI'OR:5 DECLARATION APPLIANCES-RFSIDFNI'IAI.
(hereby affinmhallnm liccmcJ unJerprnvisinnmmcncingwilh SCRII'I'ION
0mZ nsofChapmr9(c
[400 Stttimn]INNB n(Division3of the Rosiness and Pnrfessions Code.and mylicase is in ,
PANELS
Lill force las effect. ,
Q/ ileo Class Lieg UPT02W AMPS
y y Date a—J'��Coni�F — 201-I"AMPS
ZO /_ ARCIII'TIiLTS DECLARATION OVER IINNIAMPS .� S .1' lR, iA E/SQ.IT.
OZ—❑ I unJcdand my plans ehull lw used vs public rereads. n
Licensed Professional SIGNS ELECTRICALTERT E R
04 OWNP.R.BUILDF.R DECLARATION SPECIAL CIRCUIT/MISC.
KOLU 1 hereby affirm that 1 am exempt from me Cmumacrnrs License law for he V
F.aOti following reason.(Section 7031.5,Business and Professions Cade:Any city or County TEMP.METER OR POLE.INST. L/If
o which rc,mm,a permit m construct,aIle,,improve,demolish,or repair any structure E J
Ao�y}� Prieto its i"amace.alsoreyuims the applicant for such permit
rile n sigoodgtemmn ]'OWI?RDI?VICIiS
�L'aSp that he is licensed pursuan,1. he provisions of the Contractors License].aw(Chapter
e o.� 9conunencin SWIMMING POOL ELECTRIC � vALUAT]ON
xo�1 (commencing Section of Division 3 of the Business and lhdessions Code) ////''����
W—N Lir that he is exempt therefrom add the basis for alleged exempt Anyvioation of ETS-SWIICHES-FIXTURES s/il
Section]03 LS by any appliamt for o permit subjau the applican 1.a civil penalty of LJJ
K � not mom than five hundred dollars L$500). NEW RESIDENTIAL ELFC`1'H SQ.IT.
❑ ],iaowncrof ihepmperty,nrmycmployms wish wugcs us lM1cirwleenmpenmWrm S'T'ORIES TYPE CONS'I'NUCI'(ON
yg_ wit l Jo the work.and the structure is not intended or afforest for sale(Sca]044,Business
and Pmfe.ssiom Code:The Contractor's License law does not apply to an owner of
properly who builds or improves thereon,unit who does such work himse]for through his
owncmpluyees.provided that such improvements um not intended oroffcmd for aide.If, OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion.the owner- �•
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE
❑ Lav owncnsllbepropcny,vat endLisively conuuning with licemcJ nmtrucmrsto FLOOD ZONE AI'N
unstorct the pmjat(Sec.II14q Business said Professions Coda)'Hic Contractor's
Licenxlawdm,snotapplymanowncrofpmpenywnnbuildsorimpmvestherenn,end PERMIT ISSUANCE
whocontrects for such pmjccts with acontmctomd livered pursuanttothe Convectors
License Law. pLTF:H-DHAINffi VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. B&P C Iia this reason BACK FLOW PROTECT.DEVICE ()If[SIDE FEES
SANITARY Y N
Owner Doc DRAINS-FLOOR.ROOF,AREA.COND. RECHIPI'x_
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
(I Ihertby affmnthatl M1ave ecenificam ofconsent madf-ireum,nr.anificamof FIXTURES-PER TRAP RECEIPT
Wmkers'Compereation Insurance or acetified copy thereof(Sce.3800.Lab C.)which PARK FEE Y N
cover,all em In ee'x under this permitECEIPT a
P Y GAS INC.INC40VILETS
Policy N BUILDING DIVISION FEES
Company GAS-1?A.SYSI'I?M-OVSH 4(13A) PLANCHI3CK PEIi
❑ CenificJ copy is herebymouthed.the city
❑ CenificJ cnpY is fled with the city inspection division. GRFASFJINDUSTRL WASTE INTIiHCF.PfOR GRADING FF.Ii
CERTIFICATE Oh EXEMPTION FROM WORKERS' GREASETRAP SOILS ITS
COMPENSATION INSURANCE,
('fhisscodon need nn,he c.... lewd ifthepcnnit is formic hmidneldn1lurs($11101 SEWER-SANL)ARY-S OHM EA.200FT. ENERGY FEE
or less)
I cenifytbm in the perf...seofthe work far whichthis petmil is issued,Isbell WATER HEATER W/VENDELEM
not employ any person in any manner w as to become subject to the Workers' PAID
Compensalionlawsof Califnmiu. Date WATER SYSIEMHEEAI'ING Mare Receipt#
O Z Applicant
O NOTICE TO APPLICANT:If,after makin,dr,Ccnifcale of Exemption,youshould NEW RESIDENTIAL PLMB. SQ.M, TOTAL:
y becmmasubjeeno the Workers Compensuumn Proslit moaf be laMa Code,you must
a > lonhwith cam 1 Ib such this t shall be deemed revoked. BUILDING FEE
Py with provisions or permr 1
CONST
LL RUCTION LENDING AGENCY SEISMIC
Z ask hereby which
that chart is v sord Soc.onlcndCiv.C.ncy for the performance of TOTAL: HLECIEIC FEE
V O the wad for which this pcmiit is issued(Sec.3097,Civ.C.)
Lender's Nl CPLUMPING II?li �•
Landers Addis,, Q'I'Y. MECHANICAL PI7RMIT PEE
U 1 ceniry that I have tail this application and state that the above information is MECHANICAL THE
>" correct.]agree to comply with all city arta county unlinanees and sate laws relating to PERMIT ISSUANCE
F briddingconstrulion.and henchynuNutixe rtpremomivesofthiscuy on cam,upon the CONSTRUCTION TAX
Uabove-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
#1'nao.amfA,,Ii,.
nnv.cnstsmal expanses whish n airy wayawrue aiainstsaid City AIR I IANDLING UNIT(10 111,1011 CFM)
fth�gramingmf,tis it.
�/• AIR HANDLING UNIT(OVER I(I,IIW CPM(
Contractor r Dam EXHAUST FOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO 100.W1)BTU) Data He°etptp
Will the applicant or future buildarg occupant store Lir handle hmmrdnus materia HEATING UNIT(OVER 100,000tlTU) A
as defined by the Cupenino Municipal Code,Chapter 9.12.and the Ilallh wd Safety
Cad,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes El No
ISSUANCE DATE
Will theupplicuntarrutumbuildingacupant use eyuipmentordevices whichuran BOILER-COMP UHP OR 1000M BTU)
Jon,uir cimannuanls.,defined by the Buy Arco Air Quality Mam,cment BOILER-COMP(OVER 100,00013'1'U) )
a
1:1 ye, ❑No NEW RIiS1UliNTIAL MEC11. SQ.IT. N
]have read the ram ins materials rt ldncments under Chapter 5.95 of be 14AR . y
California health&Safety Codc,Sections 25505,25533 and 25534. 1 undersand that (� l 90(1
if the buildingdacs not currently have a tenant,that it is my responsibility torridity the q /Vs�
as p'm of nm n. virerem,which.,a,,Be mel Pdm m iomance of u Cerufi� c of $,v!!w
s.
Ocapancy, laUf2f'!!ln�.
Owner or umh rrrzcd agent Date TOTAL: ISSUED BY:
OFFICE