24515�OC
qaad
Fin
NaV
O'OL`=C
kOa�
�Ia,Oa
gagay#:
a�pC
o�.
til S�v
0.3
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CPPYOFCUPERTINO BUILDING-F.I.EC'I'RICAI.
APPLICATION/PERMIT PLUMB1NG-MECHANICAL
BUILDING DIVISION BUILDING PROJECT' IDENTIFICATION
PURMIB'NO. �]
2 4 515
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SSUUBMI'ITAI. DATE
/'
CUNIT# 'CX^ I.OT#
' I—
OWNERS #AMC: PHONE:
I
CON'TRACTOR'S NAME: LIC NO:
N/C
CONTROL#
❑
A
ARCO II'1'HCUEixGIN PER: LIC NO:
ADDRESS:
CONTACT: PHONE:
�+
1 q n/� / / \ IS� g4� r�
QTY. ELECTRIC PERMIT FEE
E
BUILDING PERMIT INFO
BLDG [ T PLUMB ECI
PERMIT ISSUANCE s�
e _
VV v�+�a l.1 'Ib0 1�
LICENSED
LICENSEDCnNedun CIOR'SDIiCLARATEON
1 hereby e[OrLI that] of RAI]O (wmmcncingwhh
Section 701) fDivision3ofthe Basimostnd Professions Cade, and my license is in
pppl.lANCF.S- RISIUENIIAL
� 1D12SCRIHION
PANELS
full foree end effect. �pQ°- ���1�� 111����
License Pax. Lic.p
UP T0200 AMPS
s
Dam Commcmr
ARCHITECT'S DECLARATION
1 amI,o,ntnd my plans ,hull he mum as public reo.Jx.
201 I(gp AMPS
OVER High AMPS
SQ. FT. FLOOR AREA
$/SQ. FI'.
SIGNS ELECTRICAL
LicensedPrnfessionnl
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby License Law the
that I am exmsin from the Cocoons
TEMP. MF,TIiR OR POLE INS'I'.
mason. ( Co
conlr,t,ainexsmrProfessions Code: Any city or county
co
requirsitpBrit
to
which nr repair any slmnare
which requires .permit recoms,thealter, improve,h
thevisiosfor PermlOofilcase La natement
Periitt
islisused
POWE0. DEVICES
that he prsurequires
the Co
9 c he is rmi licensed pursuant m the provisions of the Commcmr, License Low (Chapter
9 (commencing with Section ]000)nfpivision3of the Business and Hvfessions Cale)
SWIMMING POOL ELECTRIC
VALUATION bra
or that he is exempt lmrefma and the basis for the vllegm exemption. Any violation of
Section 703 S by any applicant fora permit subjects the upplicam co a civil penalty of
23 V
OUT -FES -SWITCHES -FIXTURES
mrot more than five hundred do]].. (S500).
1. sownemfthepmp rty,ormyemployeeswithwugesastheirsolecanpensatioo,
NEW RF:SII3IiNT1AL ELRCIH
S .❑
— QPT.
STORMS
TYPE CONSTRUCT ION
will do the work, and the suumure, i ante intended oroffered forsele(Sec. 7 4 ,Business
and Professions Code: The Commcmr, Liceoue Law does or apply to an owner of
propertywbobulldsorimproves themm,and whadocssuch work himsclfortnmugh his
nemployees, provided that such improvementamenor intendedoroffered handle, If,
OCC. GROUP
RES. UNI IS
T
however, the buildingor improvement is sold within one year ofcompletion.the owner-
builder wil l have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale).
C3I, as ownerofthepropeny,vmexdusively comraning wiN licenud mmrectors ro
19.00D ZONE
APN
construct the project (Sec. 7044, Business and Professions Code:) The Contractors
License L.wdoesnm applYtemnwnerofpropcny whobuildsrnimpmves thereon,nnd
PERMIT ISSUANCE
whocontracts fur such projects with a emmuctons) licensed pursuant to the Contributes
License Luw.
ALTER - DRAIN & VENT- WATER (FA)
FI7E SUMMARY
❑ 1 am exempt under See. , B & P C for this reason
BACK PLOW PROTECT. DEVICEU
SIDE .ES
Owner Dare
DRAINS -PhOOR.HOOF,AREA, COND.
SANITARY YN
RECHIPI'#
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Thereby ullimuhmlhuve ncertificnm of connate ro self-insure,mucertificam of
Workers'Compenswine Insurance or acenified copy therod(Sec. 3800, I. ah CJ which
FIXTURES - PER TRAP
RECEIPTp
PARK FEB Y N
�
covers .11 ��e111nnn1111���y,�-�yd 'Retenl'f�
holicyIt 1aa{--T _I CS�
GAS- EA. SYSTEM.] INC. 4 OUTLETS
RECEI #
BUILDING DIVI ON FEES
Co. Pony-c�(iY[OV,1,
GAS - FA. SYSTEM OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREASEgNDUSTRL WASTE INTERCEPT OR
GRADING FEE
XCaoilied copy is ]!led with the city inspection division
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSIIRANCH
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT,
ENERGY ETH
Mrseactionmced notbecompinedifthepermitisforone hundred Jollara(SUAB
m Fess.)
WATER HEATER W/VENTIELECDI
I cervi fy that i n the performance of the work for which this permit is issued, I shalt
not employ any person in any mmner so M to become subject to the Workers'
PAID
Comlerearionlawsof California. Date
WATER SYSTEM/IREATINO
D e Receipt
Applicant
NOTICE TO APPLICANT:ILafe, making this Ceti of P.xeraption,you should
NEW RESIDENTIAL PLMB.' SQ, M.
TOTAL:
become subject to the Worker's Compensation provisions of the Libor Ede, you must
ILD EPEE xiliss
forthwith comply with such provisions or this permit shall to deemed revoked.
SEISMIC FEC
CONSTRUCTION LENDING AGENCY
1 hereby vffimi that them is a construction lending agency for the performance of
TOTAL:
ELECTRIC
the work for whi his_pcnn;t is issued(Sce. 3097, Civ. C.)
Lenders Nunm111 E1,►1>L
QI'Y. MECHANICAL PERM IT FEE?
PLUMBIN MT,
Leader's Address
I cenify that I have read this application and stain that the above mormidim',
meet. l agree m comply with all city and county ordinances and state paws relating in
PERMIT ISSUANCE �I
Ae— 19
MECHAN AL FEC
building conaoucrion,and hereby authorize mu
prenmusesnm frhisciry entaupon the
abo -m
veentioned property for inspection purpses. o
AIA ER OR ADD TO MF.CII.
CONSTRI 'PION TA%
(We) agree m sive, indemnify and keep harnle,a the City of Cupertino agalmr
liabilina judgments, amortraq expenses which may hinny waymcrueagalnot said City
AIR I IANDLING UNIT (TO 10.000 CFM)
in ncc oft egrw 't of this permit.
j1 /_ _
hwi
AIR HANDLING UNIT (OVER 10,001 CFM))
Signume of APPllutnt/Co attar Data
EXHAUS'I'HOOD OODUCIj
PAID
UrATING UNIT (TO 100,000 BTU)
HALA�DOUS MATERIALS DISCLOSURE
Nee Receipt#
Will the applicant or future building occupant store or handle hazardous material
m defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VEX]ILATION FAN (SINGLE RESID)
Code, Somm 25532(.)? ��H//
❑Ycs. yy No
- `
Will the applicmtorfumrcbuilJing tamarind use equipmemoNevi<eswhich emit
BOILER- COMP(3HPOR 10y" BTU)
SSUANCEDATE
BOILER -COMP (OVER 1 00,000 RITZ
lar.uh us it contaminants as defined by the Bay Arm Air Quality Management
District?.
❑Yc, gNo
{�y
NEW RESIDENTIAL MECIL SQ. Fr.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Healdi&Safety Cade, Sections 25505,25533umd25534. land ersmmdthut
if the bnilJinp does nal currently hvvc a mmmr.0m it is my responsibility m omify the
c,arm R rM1e rcyu Rmenr. r ice man be met prior to issuance of v Can ewe n1'
11MlJYWW'`Y
NUV �� _�wxs,
Oe
4
{ l�Y
IS tiE BY:
Own ramhudze .gen ate
1
OFFICE