24543 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINORICAL PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 24543
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: II /� fb/L/ I SANITARY NO. APPLICATION SUBMI TEAL DATE
O '�� STQ ✓fibs Cr! unlTa LOr# �r
OWNERS NA F.: / /. /' P N':. CONTRACTOR'S NAME: �I LIC NOp
I/P COO 5D9�Q 30 /v� lna-Tree) NS .J..)C 2(Y7S NIC CON TROL#
ARCH 1'II:C'I'/ENGINLLR: LIC NO: ADDROS mss,/O� � C� 9��C) ❑
CONTACT: PIIONE: �/ `�•T
{{s� ((�� 1I 1-�s/�!t, / QTY. ELECTRIC PERMIT FEE BUILDING PERMITPLUMB PO
l.�.rrGQ /7C.II�I G� C f fel�/ BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
IQWz Ihdodi"ffirmthat lam liecnscdumder EarsemonsofChvptv9(commrncingwim JOB DESCRIPTION
~OOj, Section o7 en d e f Division vn 3.fthe Busiticiu m�d Rgdiatio'o'ly Code,andel my license is in PANELS (� 'sr.�
1<I License ELOa Liaa -J 1 I � /! f �' UPTO 200 AMPS L J [iia
m<� Date[ ') -`fes-Canuactor171�/k\ 201-light AMPti
ZOvtns� ARCHITECTS D: LA ATI OVER 1000 AMI'• FLOOR AREA,
O Z-O I undemm�d my plans shall be assd ns public records.
FyFSm SIGNS ELECT CA
g C W Lic<rred 14ofeasional
OWNER-BUILD ER DECLARATION SI' IAL CIRC T IS
iqa5(�O W O hereby affirm.(Se that 131.exempt from thel Pr Contractors e:Any Law tar the
W'3 0.ti which following s a ermit to on L5,construct,amass a prove,demols CnJe:Any city or county q'E '.M .R O L S'1'.
F-40Q whichit.imcsne,rilmtoafetalma improve,demolish.firepairanyswcmrc
f Y� prior to ils isauantt.nlsu requiresthe applivvm for such permiuo fileasigneJ am¢mrnt POWER DEVICES
W p seat m is licensed with
euant ra the)of Diiom nl the Contmnors License Law as Cener
0.0.09(commencing SWIMMING I'OOLfiLF.CfR
X ( gwith Section Division Sof the Business and Rofesaions Cade) ft VALUATION
W- o or that he is exempt thercfnnn endthe basis for the al leged exempt on.Any vlohnion of
F-Z¢ Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of OUTLETS-SWITCI IIiS-FI U
nm more than five hundred dollars(5500).
Ro ❑ Lasowmerofflepmpeny,armyemployees with wages astheirsolecompersdion, NEW RESIDENTIAL ELECTk STORIES TYPECONStRUCT10N
yam wiildo the work,and thestrunure is not intmdedirreffernl forsule(Sec.704,L Buainesx
and Profevsioaa Code:The Coatmgors License Law does not apply to an owner of
propony who huildsor improve,thereon,and whodoes such work urnadiforthmugh his OCC GROUP 8135.UNITS
sun employees,provided Ono such improvements sere not intended or offered for sale.If,
however.the building or improvement is said within one year of completion,the ownm-
builder will hoesdicburdenof ovin that he did not build or int for f TOTAL:
pr g prove purynu o
sale.). QTY. P BING PERMIT' 1 AP
❑ 1,as the an Oct(Sc
.7044,m Humus,andly lifetime...
th Codd)Ti contractors to M U T 1
License the project(Sec.t)anc Business and Professions Cndcp Tim Contractor',
who
trawldides forsutepplyhtanownerofpmtperty whosed puorimpmves thereon,and P13RM1 SUANCI3
who mnLrow.forsuch projects with aconvunnr(s)licensed pursuannathe Commnors
License haw. IV—ER-DRAIN&VENT-WATER(FA) y
❑ 1 um exempt under Sm. B&P C for this reason BACK FLOW PROTECT.DEVIC13 SANITARY Y
Owner Dale RIi9=x
DRAINS-FLOOR,I100F,AREA.COND.
WORKMAN COMPGNSA'1'ION DECLARATION SCHOOh TA% Y N
❑ IhereM1y affirm thetlhuveacenificem of rnnaenno self-insure,oracenilicme of R13C13IPT#
WoB:eri Compensation lnsumnce oracenifiW copy thereoflSec.Jg00,Inb CJ which FI%TURCS-PER TRAP PARK FEE YN
coven all employee's under this permit. RECEIPT#
GAS-G.SYSTI3M-I INCA Ol1Tl.li1 S
Policy# BUILDING DIVISION FEES
Co ny GAS-EA.SYSIHM OVER 4(EA) PLANCIIECK FEE
nilice)copy is hereby fumished.
Cenified copy is fled with the city inspection division. GRIiASFI1NDUS'IRL WASTE INTERCEPTOR GRADING FEI7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tbisscdinn neW not beemin,Medi,he pernitisfartnchadowi dolbvs($100) SEWER-SANITARY-STORM EA,203FT. ENERGY FEE
or less.)
I certify that in the performance of Ne work for which this permit is issued,I shall WATER HEATER W/VFNT/EIXCIR
not employ any pirate in any reamter ao an to become subject m the WorkersPAID
ComperadionlawsdCnlifomia. Date WATER SYSTEM/BEATING Ilam Rceeiptp
Q 2 Applicant
NOTICE TO APPLICANT:If,after making this Cerificme of Exemption,you,should NEW RESIDENT IAL PLMIL SQ.ET. TOTAL:
(q become.suhjecno the Worker's Compensation provisions ofthe Lubar Code,youtnum
Ki 7 forthwith comply with such provisions opermit
r this shallmco
be deemed rekel. BUILDING TEE
0. []
CONS'IRUC ION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that is a consiuction lending agency for the pwfommnceof
Or the work for which this peremi is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC THE
IT. P Lenders Name PEUMBING FEE
O U Lenders Address QTY. MECHANICAL PERMIT FEE
1 certify that 1 have read this application and sura that an move information rlidimm is
corer.I agreeconstruction,
to comply and hereby all ciryarul representatives
osamd aumlawstiporim PERMIT ISSUANCE MLCIIANICAI.FEE /
I-' buimingconeran!property
hcrebspecti npmprses. Ives ofthin city to enter upon the CONS'IRUC IONTAX
(„) 7 nMv(We)agree came,
e, for inspection purpose,. ALTER OR ADD TO MECH.
rte- (We)agree to ave,indemnify end Jude,may, ss the Ciiyentalenino against
liabilities,judgments,Costs and expenseswtich muyi any way accrue against said City AIR HANDLING UNIT(TO 10,U0)CPM)
in corse ce of the gmnf
AIR HANDLING UNIT(OVER tgap CFM)
eSignat re of icam/CmErwr Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE ❑EATING UNIT(TO 10X1,080 BTU) Dara Receipt Is
Will the applicant or future building occupant store or haddhe hicandous materiel IIGTING UNIT(OVER 100,008 B1V) T'
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(n)1 VENTILATION PAN(SINGLE RLSHH
❑Yes PIC,
ISSUANCE DATE
Will the applicant orfutumbuilding occupant useequipmed ordevices whichemit BOILER-COMI'(3H1'OR 100,1X10 R'TU)
istrict7us air conmmimnD fine
as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
/
❑Yes eN`I NEW RESIDENTIAL.MECH. SQ.FT. A p
1 have read the limandous materials requirements under Chapter 6.95 of the �'i Y
Cxlifomin l Revd,&Safety Code,Sections 25505,25533 and 25534.1 understand that DEC
iftbe building Jces not currently haves #mads.....my responsibility to notify the ��#((`�`�
occupant of there u'emems to c p6 m issuance of a Certificate of
Occupancy' ww
/Z--2—fZ r��^�/'��s�/�y� /�y/1
Owner nr mbrn eil nt Date TOTAL: ISSUEDBY: Ll Cfll llyl/
OFFICE