24516APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINOHui1,DING-F.LEC'L'RICAL•
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECIADEN'rIF1CATION
PERMIT NO . ^ s�
L IVB Vh
BUILDING ADDRESS: ^' •^O (�
3S0UNIT p L4 ai�LOT M
SANITARY NO.
APPLICA'110N SUBMITTAL DiVOU
I'/
OWNERS NAME: PHONE:
RACTOR'S NA F.: LIC NO:
N/C
❑
^CON...�T��ROL,�p
1� 1
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A HITECT/EN NEER: I_.IIC NO:
A/D--D�RRESS:
SJ�
CONTACT: PHONE:
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ONIJ kLOW (1415 J Ts7—ZQ ��
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Dc rLECT PLUMB e
n
kb —�
TL PERMIT ISSUANCE l
LICENSED CONTRACTOR'S DECLARATION
1 hereby affiml that ern licensed under provisions of Chapter 9 (commencing with
SdOion]011U)of Division 3ofthe Busincssand Professions Code,ond my license is in
APPLIANCES-RESID AL
JOB pESCRIPTION
PAN.?LS
full fortyxndcllact. ttt111/�
LhccnxckI s, #
UP 20
U
S'
Dam j cdulc ter
ARCHI ILLI -S DECLARATION
I understand my plans shall be used as public records.
1-1000 AMPMPS
G R I N
SQ. IT. FLOOR AREA
S/SQ. IT.
SI S[ ICAL
Licensed Professional
OWNER -BUILDER DECLARATION
PL LCIR IT S(
1 hereby Itllinn that I am exempt from the Contractor's License Low for the
TEMP.MET R .]NST.
following reason. (Section V031.5.13mhess and Professions Code: Any city or county
which requires a permit to dembuct,.Imr, improve, demolish, or repair any umcmre
primer its issuance,aha requires theappliermaforsuch pertniva filed signed statement
POWER DL S
that he is licensed pursuant the provisions of the Commutes License Law (Chapter
9(commencing with Section 7")of Division of the Business and Professions Code)
SWIMMING OL ELECTRIC
of
orthotheisexempt therefrom and the hc.ut,nheaB thedeficaut to viviny l actually
Sermon "10i L5 by any upPlicam for n Pemtit subjects the upplicnm m a civil pemllty mf
(C�/�VAIGOMM
•fir
OUTLEI:S- SWITCHES -FIXTURES
and more Nan live hundred dollar,
❑ 1,asowneroftnepmpery,ormyemployceswiNwagesaslheirsolecompensaiion,
V _
EWRBSIDENTIALECTR _SQ,
LF. PI'.
STORMS
'TYPE CONSTRUCTION
will do the work, and the swaurc is not intendedoroffded forsole(Sec.]04 ,Business
and Professions Cade: The Contractor's License Law does not apply to an owner of
propertywhmbuildsorimprovestheremn,andwh`d.. suchworkhimulfiethmughhis
wnemployees.providedthatsuchimpmvementsarenotintendedoroffcmdforsole. IL
OCC. GROUP
RES. UNITS
T
`
however, the building or improvement lssold within one year oreompletion,theowner.
builder will Imve ilio burden of proving that he did not mild nr improve For purpose of
QTY. PLUMBING PERMIT FEE
tele.).
[:]I,asownerorthepmperty,amexclusivelyconnctingwithlicrnscd,.n"m torsto
FLOOD ZONI?
IN
conemret the project (Sec. 7014, Business and Professions Code:)The Contractor's
License Lawdocs not applym an ownero(proparty who builds or improves thereon.and
PERMIT ISSUANCE
whocontmers for such projects with a contracoms) licensed purmuant to the Contractor's
License Lou.
pLTI!B -DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , 13 & P C for this rcus.a
BACK FLAW PROTECT, DEVICE
UTSIDE FE .S
SANITARY YN
RF.CF.IPTp
Owner Dom
DRAINS - PLOOR, ROLE, EA.
WORKMAN COMP'IONDECGRATION
SCHOOL TAX Y N
C3Ihemm hereby afrrtM1alhave acerificatcGcate of coni theroo(Sist. re,m Lot C.) which
Workers'Compensaion lnsumnceoruceniredcopy Nercnf(Sec. 3800, Wh CJ which
RECGIPI'p
FI%TUB13-PER TRAP
PARK FEF. YN
GAS-G.SYSTEM-1 INC.4OUTLETS
covers II m Inyo++y dgLthisp5ryt
Policyk-`�jEolrns]1;g L.J
RECEIPTS
BUILDING DIVISION' ?S
PLANCI IECK FEE
Company S)��— ���
❑ Certified copy is hereby famished.
Certified copy is filed with the city inspection division.
GAS - EA. SYSTEM -OVER 4(EA)
GREASIVINDUSTRL WASTE INTER CEPTOR
GRADING ME
CERTIFICATE Or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ORGSI!T'RAP
5011-S FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be, completed ifthe permit is formic humbeddollare(SI00)
nr less.)
WATER I I I!AI ER W/VEN'I'/I!I,FCTR
I cerci fy that in the performance of the work for which this permit is issued, I shill
not employ any person in any manner so as to lacerate subject to the Workers'PAID
WATER SYSTEMTREATING
Compenmtiou Lawsof C.lifomia. Date
Applicant
te Reviola W
NOTICE TO APPLICANT. If, aper making this Certificate of Exemption, you should
NEW RES) DElx`OAL PL.MB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such presidents .,,his permit shall be domed revoked.
BUILDING FEE
CONSTRUCTION LENDING AG13NCY
SEISMIC FEE
I hereby afrrm that there is a construction lending agency for the Performance of
TOTAL:
Ii1.ECIRIC FEE
the work for whiy� I, I, issued (Sec. Ln?, Civ. C.)
Lenders Namc 962
1<nder's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I cart that I have read this application and state that the above information is
rnwo. l agree m comply with all city and county ordinances and state laws relaingm
PERMIT' ISSUANCE ��
MECHANICAL PI i
building cm,umush , and hemby vudim I,, rcproacce, ves of lhi—ty toemer, upno the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECI I.
CUNS'I'RUCTION 'A%
(We) agree to save, indemnify and keep harmless the City of Cupertino.,.last
I!.bilitiu 'uda, ensu dexPeves which may in any wayacameagunst said City
AIR HANDLING UNIT CI -0 1(1,0(10 CFM)
in coace of mg ni of this permit.
AIR HANDLING UMT(OVER IQIXIOCFM)
Sign.um of Appixonl Contra sr - 'para
EXI.AUS'1' HOOD(W/DUCIO
PAID
HEA'T1NO UNIT (TO 100.0001 IO)
HAZA US MATERIALS DISCLOSURE
Date Receipt N
Will the applicant no future building occupant store or handle hazardous material
ino
as defined by the Cuper Municipal Code, Chapter 9.12, and the Heah hand Safety
HEATING UNIT 100,000 BTU)
TOTAL mp—atitiv
Code, Section 25532(x)?
❑ Yes YIN.
VENTILATION FAN (SINGLE RESID)
Will than Ilnmmrfmuahuildin tusae tnrJevices whiehemlt
pp l by the equipment Air
hazardous air mnmminwts m definul by Me Bay Arca Air Quality Management
District? ✓✓✓
❑Yes YIN`
BOILER - COMP (JHPOR IW,(lUO BTU)
ISSUANCE DATE
T
C
A/O
BOILER - COMP (OVER IW,gN) DTH)
NEW RESIDENTIAL MFCII. SQ, Fr.
1 have read the ha'zard`ous tamed.], requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the buiWim,dom,mi currently navenecram, that it is myresponsdolitym notify the
the re i ement which must lie met prior to isaaanec ter Cenircam of
y'r 11 25 19
i�/ 9i
wry N7�
ur uu' .
-
o`utpant
II S
C i
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{y�
ISSUED BY�
Owne r ionom
.gen Da <
OFFICE