24635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT-INO1. GFE
R,'RI AI. rI:RMn'N°'
APPLICATION/PERMIT PLUMBING-MECHANICAL 24635
BUILDING DIVISION IIIIILI)ING PltOJE(PI'II)IiNfIF'ICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'I-I'AL DATE
O OD SGB UNIT# LOT# '
OWS PHONE: ONTRA60 'SNAME _ hIC NO � N/C CON TROL#
ARCHR iCT/GNGINBIR: LIC NO: ADD $.O �F�•"/"t O S ❑
CONTACT: I PHONE: 4 r BUILDING PERMI•f INFO
QTY. ELECTRIC PER IT FEG
BLD ELF. PLUMB MIiC11
PERMIT ISSUANCE C /aa ❑ ❑
LICENSED CONT'RACIOR'S DECLARATION APPLIANCES-RESIDE 1. JOB DESCRI 10
�y. Ihcreby affirm thalam licensed ondttprovisionsof Chapmr9(commenting with �� 0 W I,
O 'etion7000)of Division 3 of the Business and professions Cale,and my license is in PANELS
Well fallforceata ewer. (�� prQQ Ems`
QV License Cless _Lic.q ✓`^�� g/2 UP T02W AMPS
rhir�y Date Cantraedr 201-I AM J Al
Z.Oy• ARCHITECTS D[CLARATION OVE SQ.FT.FLOOR AREA $/SQ.PT.
OZ-0 I understand my plans shall be used is public records.
Qt� E DUCAL
YS„'ISNSj Licensed Professional \
�y
OWNER-BUILDER DECLARATION CIA.CIRCUI'1'/MIS
XM
I hereby orifi tI'
hat 1 am exempt from the Commences License Lew for the
W of following renourn(Seamn 7(315,Business and Profcoinns Coda:Any city or county T P.MBTE P L.INST.
tU.0; which requires.Permit to curstram,alta,improve,demolish,or repair any Structure -
�d <� prion,it,issurae,ulsorequires the applicant for inch Permit to rile a signed statement POWER DEV ES
tt.
m_ Oz @m he is licensed pursuanua the pmvisions of the Conwaoes license Lew(Chapter
9(commencing with Section7")of Division 3 ofthe Business and Prefessiom Cade) SWIMMING RLECfRIC VALUATION
onhm he is exempt therefrom and the basis for the alleged exemption.Anywiolation of OUTLI>15-SWI'fC1TIiS-FIXTURES
F Z� Section 7031.5 by any applicant for a permit subjects the applicant m o civil penahy of
�ZG nut mora than five lmndumdollara($5W).
C1I,usownerofthepropeny,ormyemploy withwagesasthcirselecompensaunn, NEW RESIDENTIAL _SQ.PL STORIES 'TYPE CONSTRUCTION
,;!2willdothe work,and the sanctum is not intended,roffened forsale(Sec.0044.Business
and Professions Calc:The Contractor's License law does not apply to an owner of
property wM builds ser irrpmves thereon,and who daps such work himselfor Through his
own employees,providedthnt such improvements are not intended oroffercd forsale.If. OCC.GROUP RIS.UNITS
however,the building mimprovement used within ane yearofco ad,lien,theowri TO
builder will have the burden of proving that he did not build or improve for purpose of
aide.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lae the ppjcO(Scp 7n . .,me v andlhhx,tiwas Code:)The manorsm
mmruet the project(Sec.ourto Business and I'r who milds
Crimponhe Crno-amand
Lirenulscts Eos ch applycourt
ac contractors)
whosed paranmprnves Norton,and pl?RMIT ISSUANCLt
who me Laws fnrsuch projects withurnmrucmr(s)licenscd pursuannothe Crmrenaes ALTER-DRAIN&VI:NT-
himnu Law. WATER(BA7 FEE SUMMARY
❑ 1 am escmpt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE 51 • •:IS
SANITARY YN
Owner Data RECEIPT#
GOND
AREA
ROOF, . .
WORKMAN COMPENSATION DECLARATIONDRAINS-FLOOR, SCHOOL TAX YN
❑ Iherehy affirm that(huveacenifieem of eonsennn self-insure.ora ceniricatc of FIXTURES-PER TRAP RECEIPT
Workeri Compemainn lnsumnce ore<eniried copy thereof(Stt.3gW,Leb CJ which PARK FEE YN
Palicy#lepiIn ..s urger thi;yd@it�/-J/ ! GAS-Ii,k.SYSTEM.I INC.4 OUTLETS RECEIPTp
//NN fi^J C-:-TYCO 7 BUILDING DIVISION FEES
C m,y r ,ru i/2dS.LZ JIIA$ GAS_HA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is herehy famished.
Certified copy Is filed with the city im,ori,n division. GREASIpINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPDONFROMWORKERS' GREASF,TRAP SOILS;FEE
COMPENSATION INSURANCE
(This action need not hecompleted if Ne permit is foronehundreddollaraDIM) SHWER-SANITARY-STORM FA.200PT. F.NERGYPEE
,floss.)
I cmify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VEN'DELEC'I'R
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califnmia. Dam WATER SYSTHMITRFAT'INC Date Receipt#
pz Applicant
z NOTICE TO APPLICANT:Buffer making this Cerificateof Exempting youshould NEW RESIDENTIAL PLM. SQ.Fr. TOTAL:
Ffq become aduccnathe Wodees Crad tuam.pmvisiansofthe Latur Codgyoa must
a forthwith comply with such provisions.,,his permit shall be deemed awaked. BUILDING FEE
I
in Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I htteby affirm Its,there is a consvuamn lending agency far the performance of
V O the work for which this Permit is issued(See.3WO,Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name
OF Leader'a Address QTY. MECHANICAL PERMIT FEE PLUMBING FEB
V I certify that I have read this application and sum that the aNrve information is
W correct.lagrcemcamply with all city unJ county ordinances and n:nc laws rdetingto PERMIT ISSUANCE MECHANICAL FEE
1--' buildingeonswctiog and hereby authorize repmsereativesofthis city reenter upomhe
V 7 .hove-mentioned property for inspectian papooses. ALTER OR ADD TO MECH. CONSTRUCTION TAX
C e ag p hapless the City of Cupertino against
ilib,ities.judgme OSc nd n ich may in an yaccmeugainst said City AIR HANDLING UNIT(TO IO,fKKI CFM)
,sequence eg n o th i5e it.
AIR HANDLING UNIT(OVER BLOW CPM)
ignature of ApplicanVCnmrecter Date EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T'O I I OMM BTU) Date Receipt#
Will the applicantor future building occupant storeor handle hazardous material IIFA'I'ING UNIT(OVER W,OW BTU) 'IDTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sentirn 25532h.)?
11 Yes No VENTILATION FAN(SINGLE RLSID)
Dhenpplicamorfmurehuildingoc<upamuse equipmentoNevices whichemit
BOILER-COMP f3HP OR 100.1100 BTU) ISSUANCE DATE
Will
O hazsndons air containments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I(gAW BTU)
Districrl
❑Yes ( NEW RESIDIiNTIAI.MECfI. SQ.fT, ffe�sss
1 have read the hazardous no.amals re,orma,ms under Chapter 6.95 of the g+ p
Califnmia Health&Safety Code.Stearns 25505,25533 and 25534.1 mWersamd that l
if the building dors not currently have a tenant,that it is my mspersibility to near,the ^��
occupant of the mqu armnai,s which mm must be met prior issuance of a Cm te ificaof a0
Occupancy. gds Q�
Owner or authorized I j �rC agent Date TOTAL: ISSUEDIOC
OFFICE �nfury