24500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOL BULI.DUSG-ELF,CIMUM, PERMIT NO. /N A4OO
J
C
APPLICATION/PERMPr PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PRGJRCT IUENTIFICA'I ION
BUILDING ADDRESS: `* � ,� SANITARY NO. AP1PLICATION SUBMMAI.DATE
V UNIT# IATA L •/ -
OWNERSNAME: PHONE: CONTRACYOR:SNAME: LIC NO:
lk {1cp-C66'. ' S - 8 03 . foo-ow.er Plcvw ,,i 6 C17, C36-62034?. N/C L'ON'IROL#
U7101ECDENGINEER: LIC NO: ADDRESS: ❑
`�'S50 <ot..,ecoLD CT. CuPC',-7-i^ 0-
CONTACT: PHONE:
. 1 71
Q'FY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIPI'ON
pyZ I hereby affirm that l am licensed unJerpowraonsof Chtitu9(commencing with
0,WO Section]BW)nr Divixinn3 of the Business it PnJesxinns Ce.lc,and mylicemeis in PANGI4 ^
It mart"mJ,ffec. 6 Li,, 6.Zd �`342, UP TO 2W AMPS 1���-
<Z,Iy License Class
re<y Dae onwc,.r 201-1000 AMPS
ZOyz ARCHITECTS DECLARATION OVER IfkMIAMPS SQ.F`L FLOOR AREA $/SQ.FT.
OZ—M I undetslnnd my plans shall M used as public records.
F rn W SIGNS ELECTRICAL.
.J..l Licensor'Profcxaimal fl
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. R
y°ql
A. I hereby urfirm that I am eacmpt from the Comrncth',Liver.Law for the
613 wFi following rcasna(genion](131.5,Business end Pmfexsinm Cole:Any city or county TEMP,METER OR POLE INST. �'�"
v�OQ IN
whichrequiress,Pewiuoconsvuct.ale,inamve,demolish,ar repair any structure
�2 pnirlo its inanove,eds.r loon Ilcamfnrsuch no fleusi dsmtemem POWER DEVICES pL ! t l J
eyuirca pp powi gne d y
61 p 0 that he is licensed pursuant m N,provisions of the Contractor's License Law(Chapter
a0.p� 9(c.mmeneing with Section 700(put'Dwision 3 of the Businessand Professions Colo) SWIMMING POOL F.LE RIC VALUATION
Wim or Nal he is eaempnherefrom and the basis for the alleged exemption.Any violation of DUTLITS-SWITCHES-% GS
4 Seminn]OlL56y uny applicamfor epcmtit subjects the applicnnuoucivil penalty of
nm more Nen live hundred dollars($500).
C p ❑ 1,asowneroftbepmpeny.ormyemployeawiNwages asthcirsolecomperue,ion, NEW RESIDENTIAL F.LECTR _SQ.Ff. S9'ORIFS TYPE CONSTRUCTION
y3,.. will do the work,and the structure is not intended oroffcrul Rande(Sec.70,14,Business
and Professions Code:The Convector'$License law cess not apply to an owner of
property who builds or improves th,imm and who does such work himselfor through his
owmemployces,provided that such improvemenuare not intended confined forsale.If, OCCGROUP RES.UNI"TS
however,Ne building or improvement is wild within one yrmnfurmplaion,the owner- TOTAL:
hnildu will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,usowneroftheproperty,am exclusively contracting with licensedconoacmrs to QTY, PLUMBING PERMIT FI7E ROOD ZONE APN
construct the project(Sec.]044,Business and Professions Code:)The Convector's
License Lawdocs not apply to an ownerot'no ny who buildsorimpmsmilicat and PERMIT ISSUANCE Irs op
whoconlouslirsuch projects with a convactims)licensedpurxuunUothe Cnntrucmrs ALTER VENT-WATER(HA)License Law. FEE SUMMARY
❑ 1 um exempt under See. ,B&P C for Nis revmn BACK FLOW PROTECT.DEVICE .ID i.FS
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Thereby affiw thatl heveacenifcae ofc.nsem msdf-insum,ora«nifcam of FIXTURES-PER TRAPRECEIPT#
Workers'Compensa,innlnsuranaeoraanifiulcopytbereof(Soc.3RIN1,Lab CJ wM1lch -11 PARK FEE Y N_
coverall employee's undeahist RECEIPT#
Policyp Pewit GAS-G.SY$TGM-1 INC.40UTLEI'S BUILDING DIVISION PEES
Company GAS-P.A.SYSTEM-OVHR 4(EA) PLANCHECK FEE
❑ Certified copy is heathy furnished.
Certified copy is filed wim,lic city inspection division. GRF.ASE/1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OIt EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS PEE
COMPENSATION INSURANCE
(This section need..,his c.mpleud ifthepewit is lattice hundred dollars($1(10) SEWER-SANITARY-STORM EA.200FT. 17NERGY FEE
or less.)
I certify that in the perfowuncc of the work for which this permit is issued,l shell WATER HEATER W/VEYCIELECR
not employ uny person in any mvna,,so as,o become subject m the Workers' PAID
Compensation Laws.f Califomia, Date WATER SYSTEM/IREVUNG Dom Receipt at
C) z Applicant
C) NOTICE TO APPLICANT:IL aper making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FP. TOTAL:
fn become subject o the Worker's Compensation provisions of the Labor Cale,you most
a `y' forthwith comply with such provisions or this pewit shall be deemed revoked BUILDING THE
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7- z Iherebywifwthaubac isa,ms,mnion lendingagency fortheperfimmwce of T ELECTRIC FEE
the work for which this pewit is issued(Sec.3097,Civ.CJ
Lend,ts Nam, -
O U Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
'1 certify then I have rend this applica cr trod slate the,the above nomination is
7" 0. correct.Iagree to comply with all city and county ordinances and sure laws calming to PERMIT ISSUANCEMECIIANICAL EEL:
�y Uj buildin,comiuctiim,ind hembynmhoriae represernnwis,ifthls city menta upon the CONSTRUCTION q'AX
V Z above-mentioned properly for inspection purposes. ALTER OR ADD 10 MECH.
(We)agree to save,indemnify and keep hawless the City of Cupertino against
Iiabili,ies,judgmems,costs and expenses which may m imy wa rue against said City AIR HANDLING UNIT(10 10,000 CFM)
in consequence of the gaming of this Pewit.
✓ ` 1' AIR HANDLING UNIT(OVER 10."CFM)
Signature of Applicant/Contractor Data EXHAUST 11001)(W/DUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicantor futureMunbuildingoccupanter 9.2.handle Healtha material
as defined by the Cupertino Municipal Cede,Chapter 9.12.and the Health end Safety HEATING UNIT(OVER 100,000 BTU) ANLAIJ
Code,Section 25532m)?
vu I
❑Yes ❑No VEN'fI WT10N PAN(SIN(SINGLENESID)
Will,he aconnotatins as building occupantuse equipment orJcitta whichemit
BOILER-COMP OUT OR 100,000 BTU) ISSUANCE DATE
uzallous air mntominanu as defined by Ne Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
isirict^ ph
❑Yes ❑No NEW RESIDENTIAL MECH. .4 1 1)
SQ.IT. I/-
1 have read,he hmnrdous materials requirements under Chapter 6.95 of,he Nov
Califomia llealth&Safcry Cade,Swtians 25505,8533 and 25534. 1 understand that
if the building docs no,currently have a brand,that i,is my responsibility m notify,be 17
^
occupant of the requirements which mus,be me,prior to issuance win Cenificvm of
Occupancy.
V (J K IIVU
Owner or vuNoriud agent Dam TOTAL: ISSUED BY:
OFFICE