24839 1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .HUILDIU-ELE.CI'RICA], PERMIT NO,
APPLICATION/PERMIT 1'LUMHINO-MECHANICAL 24839
���IN
is 3
BUILDING DIVISION IIIAI.DINGPRO.IRU'TIDEN'IIHICLATION 49
BUILDING ADDRESS: SAND'ARY NG. APR.ICA'1'IDNSUBMITI'ALDATT:
UNIT# LOT,
O 'RSN �� IIE��.a oO NTR OR'SNAME: LIC S N/CCONTROL#
ARCOII'I'IiL1'/IHJCINIiER: LIC NO: DDR ❑ -?
t
CONTACT: PHONE:
QTY, ELECTRIC PIiRMIT hEE BUILDING PERMIT INFO
Gr '.r LurcH Lpc
�i PERMITISSUANCE ��►
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-R IDENTIAL
OmZ dor
I hereby affirm Nsa
at l am licensed under pvisionsofatipter9(commencing with JOB D[SC ION
LL100 Section 9001 Division 3 of the Businessand Professions Code, it.,license is to PANELS
FFj r'1 F full form:nd effect. � ,
G tEw License Class LicitUPT020VPS' _
N,N Date Contm um - 0 PS
Z OO7nz, IARCHITECTS DECLARATION ER SQ.FT.FLUOR AREA 1/SQ.FT.
CZ-0 unJenand m
ty plana shall Named ss ca
Public rents. kill
^ ��`J
LicntseA Professional EMRICAL r
OWNER-BUILDER DECLARATION S E FALCFRcurOldISC.
xdx OaU 1 hereby affirm that I vat exempt Tons the Contmctoes License Isw for the u
W 3 LL v[—i following reason.(Section 7031.5.Business and Professions Code:Any city m county P.M 'R O
which raptures a permilto construct,Act,imp rove,demnlish.or repaireny stmemre
}� priurto iteIssuance,nlsn requiresthe epplicnm for such perminn fleasigned elmement PO DE I ES
�0 mat he is licensed Purvmmlm the provleionx of the Commemrs Lleense low(Chapter
9(commencing with Seclion 7")of Division 3 ofthe Business and Potassium,Code) I NC OL ELF.CIItIC VALUATION
_m or that heisexeb therefrom and the Permit subjects
the
dexemptt to civil
of OUTLE -SWITCHES-FIXTURES 122 13, W
Z Q Smion](131.5 by any applicant for a permit subjects the applicant to n civil pcndty of
Eli
not=.ban five hundred Aollnum($500). NEW RESIDENTIAL EL[CT
❑ I,nsowneroftheprnpany,ormyeniployeeswithwagesuvheirselecompensation, STORIES '1'YPU CONS'1'SUCTION
L will daliework.and the structure isnot intended combated forsde(Sec.7044,IIuvinaw y
and Professions"c: Um Contractor's License Law data not apply to an owner of
pmpenywhobuildsorimproves thereon.and wineries such workhimselfonhrougmers
If, OCC.GROUP RFS.UNITS
own employees,provided that such improvements arc not intended m offertA for sale.
however,the building or improvement is sold withinone yearof completion,the owner- TO
builder will have the burden of proving that he did not build or improve for l mpose of
e)
er of theprnpeny,am exdwivelycontraning with licensed ennwemrstn QTY. PLUMBING PERMIT FEE FLOOD ZONE' APN
struct the project(Sec.7014,Business and Professions CodaO The Comracmcis PERMIT ISSUANCE
icenu"'it not a pplytounownerofpropenywhobnildaodmproveathereon,and
who rater!forsvohprojects with a conuvetor(s)licensed pursuant to the Contractor's
Llano haw. ALTER-DRAIN&VP,N'P-WATER(BA) 1°Til?SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDEFEES
SANITARY YN
f Owner - Date pRAINS-IL RECENT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherchy affirm that lhave ecenifcate of consemmself-insure,ora certificate of TURNS- AR -•"�� RECEIPT#
'Workers Compensation Insurance ora cenlEcd copy partial N..380DI.ab C.)whiuh is PARK FEE Y__IN
Y? covers all employee's under this petmil. RECEII'1'#
). Policy, AS-E SY IN TS BUILDING DIVISION FEES
Company dr.S -OVER4 I PLANCHECK FEE
❑ Centric copy is hereby furnished.
❑ Certifed copy is fled with me city inspection division. G BASE N USTRL AS?P. ERCE f0GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SEIRAP SOILS LIE
COMPENSATION INSURANCE
(This section need not becmmplered ifthe permit is forome hundred dollars($100) SF. ER-SANH' Y- "ORKIEA.200FT. ENERGY FEE
mrlesa.)
I certify that in the performance of the work for which this permit is issued,Ishall W T I'AMR WNEMf/CI.EMR
not employ nny persun in any manner so us m become subject m the Workers' PAID
Z Compensation Lawsof California /F
. Data WATER SYSTEMREAI'INGDvl Rmeiptp
Applica t
O0 NOTICE TO APPLICANT.If,after making this Cenificum of Exemption,you should NEW RESIDENTIAL PLMH. SQ.FI'. TOTAL:
� 1;0 become subject to the Worker's Compensation provisions of the Labor Code,you must
fxthwith comply with such provlsma,.,,his pennh shel l he deemed revoked. BUILDING I:
RW. (] CONSTRUCTION LENDING AGENCY SEISMIC EE
Uz I herebysffirm Barbarais a consnutaion hodingitumi,far Ne perfnnnvnce of [CECT IC FEE
O the work far which this Permit is issued(Sec.3097,Civ.C.) IgIll
(1. Lender's Name FEE PLU KING FEE
Lender's Address QTY, MECHANICAL PERMIT I'''LL
C) I certify that I have reed this application and state that the above information is
corrcet.Iagree locomply withall
authorize
riz county ordinances and state laws relating to PERMIT ISSUANCE ML'Cf NICAL FET:
E"' N buiWingconstmctioq and hereby authorize mprtaemativa of this city tnen¢r upon he
L) above-mentioned propeny for inspection purposes. ALTERORADDI'OMECII. CONST CDON TAX
(We)ugmr m save,indemnify and kttP harmless the City of Cupanlnn ogviyst
liubiliiicsjohimnta.atstsmtd expenses whielh Inanyw 141. f51R1 f/ry AI R HANDI.I NO UNIT(TO 1(1,1100 CFM)
inc nsey ee of the gntming of Nis peri '. •y,��.7///
AIR HANDLING UNIT(OVER 10,000 CIM)
Signature of AP cant/Cmrtmctor Data EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT'('TO 100,0p)BTU) Data ciPl#
Willthe appliwntnr future baibrollaceupantsmm or handle hazndoua metend HEATING UNIT(OVER 100.000 BTU) AL:
as defmod by the Colorist Municipal Code,Chapter 9.12,and me Health soil Safety
Code,Sttti 11Yes ❑No 25532(n71
❑ VENTILATION FAN(SINGLE RESID)
Will lhce licam orfmumbuildin tune imentnr devices ash, BOILER-COME(3HPOR 1(X1,000 BTU)
ISSUANCE DATE
PP &byfluxn equp
hazatdom air contaminants as define)by Ibe Bay Area Air Quality Management
District? (X
BOILER-COME(OVER 100, 0 BTU) as
If+If A
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. B^ Q
I have rend the huziniksm maloirls requirements under Chapter 6.95 of the ^rA ]�
nuc Caribo is Health&Safety Code.Sections 255115,25533 and 25534.I understand that `, R
ifcubuildingdosorcurrently have atenant,that it is myommucaiof. rnotify me
ceche building
of the requi t clams which man u Inez prior m issuance of o Ceniotifm of
le �rY
Occupancy. //� /
01 091
Owner or nwhnrized agent hate ISSUED BY`
OFFICE