99120127 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Jr
CITY OF CUPERTINOBJIITil,c•.�-ET,L�'I u1cAL PERMrf O.�
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDRN'FIPICATioN
BUILDING ADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE
0735 silFy" 5 ne rAeov • eill'URVO , CAUFo i o# '�22
OWNERS NAME: _ PHONE: CONTRACTOR'S NAME: Q NO:
w�5 C/o CWeE75-1 rte"175 - OvT 7V 0' • S� 7 )� NC CONTNOI,p
11'IEC IENGINFE LIC NO: ADDRESS: G �� Elr • t.4Wr)45nlCE MVSIL C-0111-33 137-7' li lave TvrfGnt 905 /
CONTACT. %Q C[r/S 0um1 PHONE: BUILDING PERMIT INFO
0. /OJ3Tib_4?6o QTY. ELECTRIC PERMIT FEC
�% BLgG ELE91 PLMECH
ACT O
PERMIT ISSUANCE, '�hW_/J' •IC�fI
LICENSED CONTRR:S DECLARATION 11 APPLIANCES-RESIDENTIAL TOB UESCRIFI'ION
Da:z I hereby affirm that l ton licensed under provisionsofClepler 9(commencing with 1
WOO Section 7W0)of Division froths Bminswicidd PPmfcssima Cods,and my license is in PANELS
luocmrce c Clad eff g` Liv.is •v ��� I UP TO 2W AMPS
,nQ a Due Comrecmr 201-1000 AMPS
Fy Z ARCHITECTS DECLARATIONSQ.FT.FLOOR AREA $/SQ.F1'.
O O N_ I understand my plans shall be used as public records. OVER I(q0 AMPS
r,4 F�W SIGNS ELECTRICAL
Qy2,, Licensed Professional' (�
ecyec6 OWNER-BUILDER DECLARATION J SPECIAL CIRCUIT/MI. .
06 U I hereby affirm that I am exempt from the Contractor's License Law for the
Say following reason.(Seetion 7031.5,Business and Professions Cole:Any city of county TEMP.METER OR POLE INS'1.
which requires a permit to construct,after,improve,demolish,or repair any structure O�
f.�Y2 pricrm its issuance,also requires the applicant forsuch,mrnd pill...ignsdnm
areem POWER DEVICES WeiO that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
°'xe�' 9(commencing with Section 700)of Division 3 of the Business anal Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_honhatheiscxempuhcrefmmandthsbasisforlheallegcdexemption.Anyviolationof ' OUTLETS-SWITCHES-Fl 72k�ti
,Z. Section 703 1.1 any apchaent for apemtit suhjecothe appllcotu'.civil parially of
E S O not more than five hundred dollar({500).
W M ❑ I,nsownerofthe Won ry,ormyempinyccswithwugesnstheirsolecompensaion, NEWNESIDEN'IIALELECIR _SQ.FT. S'PORIIS 'TYPECONSI'NUCTION
p�,322 22 will do the work.unit the swcwre isnot imendeJurolfend forsale(Sec.70gL Business , Ir,g/
and Professions Cale The Contractors License Law does not apply to an owner of V �It
pmpcny whobuilds nr improves Ihemnn,and he does such workhin aelfc r through his
cmployau
s.provided thaummnt
ch impvccsme not iMeadedoroffeted forsile.It, 'OACC. ROUT' RES.UNITS
however ,the building or improvement issold within one yearofc.ametion,tM1C Ownef- 'TOTAL:
builder ill have the burden of proving that he did not build or improve for purpose of Enrpt
Ic.
Lxs ownerrflbe prnpcnY,amex<IusivelycnnlnclingwiNlicensW nmtracens to QTY. PLUMBING PERMIT FEE I:LOOD LONG APN
Lmstruo the project(See.7010,Business and Professions Code:)The CContractor's7/ 17 D
icense Law dictatorially loan ownuol'property who buildsor impmves Nereogand PERMIT ISSUANCE? W X�
who contracts oorsuch projects with ammmemr(s)licensed pursuant mthe Crntracmr's ALT, WATER LA
License Law. (' ) FEE SUMMARY
❑ lamexemptunder See. ..B,.f Cair barmaon BACK -DRAIN&VEN DEV uTSl1Jhrl"Es
SANITARY Y N
r Dam i RECEIPT#
DRAINS-MOOR,ROOs OND.
mer WORKMAN COMPENSATION DECLARATION SCllppl.T'AX YN
I hereby affirm that l have a cenifical of self-insure,or a certificate of FIXTURES-PERT RAP RECEIPT#
en '
Wgi4em'Componsionn Insurance or a cefi copy hermf(See 3X00.Lab C.)which PARK REL Y N
cis all cmWovLivul l�7lhit rcm3i Lit { �I 6 RECEIPT'#
bli<y M
/ACV V' GAS-F.A SYSTIiM-I INC.<Of1T1.F. . BUILDING DIVISION FEES
Company 'v /.ifs GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING ITE
CER'T'IFICATE OF EXEMPTION FROM WORKERS' GREASE IRAP SOILS FBI:
COMPENSATION INSURANCE
(TibsectirnneednolbecompleleJ ifthepermit isforonehundreddulluts(SIOB SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I anify that in the performance fthe wnrkfor which this permit is issued.l0all ' WAI FR BEATER W/VENfpiLEC1'R
not employ any person in my m m to become subject m the Workers' PAID
Compensmirn Lawxof Cvlibsmia. Date so WATER SYST940UR SATING Dam Receipt#
z Applicant
z � NOIICE 10APPLICANT:If,aftermakingthisCcrificamofExempnon,ym,hoild NEW RESIDENTIALPL.MB. SQ.FT. TOTAL:
P: fA become sobjeel m the Worker's Compensation provisions of the l.ebar Cade,you must
fonhw ilh comply with such Provisions or this permit shall be deemed revoked. BUILDING FE"H
Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm Thal Ncre is i sued Sc tan 97.Cig.C.)agency for the perfrrmnnco of
U O the took far which this permit is issued(Stt.3097.Civ.C.7 'TOTAL: ELECTRIC FEIi
Lmdais Name
Lk. lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING REE
F
U 1.I agree
that 1 have read this application and state the the state laws
is MECHANICAL FEE
7` F>a building Eagrccro comply with
yroocity and county and anile entrelatingm PLRMI'I'ISSUANCE
F" Z those-memitauairmand hcrabyau0oriureprescmatives of this city mentor upon the
U z udwe-mcminnW property for inrpadnn purpsscs. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(Wed agree losave,indemnify and kap h:umless the City of Cupertino against
Iiahilitics,judgment,s,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFMI
in consequence of the graming of Nis permit. '
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanisCummebr Dam EXHAUST FOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,000 BTU) Dam Receipt#
Will Ncapplicam or fuum,building octupanlamc rr handle huardous material HEATING UNI'I'(OVIiR 100,t1(NI B'TU) TOTAL:
as derived by the Calcium,Municipal Cods.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION BAN(SINGLE RESID)
❑Yds ❑No ISSUANCE DATE
Wiltheapplicanlarfutumbuildingoccupam usccquipmcnmrdcviceswhichcmil BOILER-COMPpBP OR 100,001 BTU) ,_,may -3- 2
Wous air or.armnsnls as defined by the Bay Area Air Quality Management BOILER-COME(OVER 1110,000 BTU) / 3- Zit
,riot? tel/
❑Yn ❑No NEW RESIDENT[Al.MEC11. SQ.FT.
111t ve:ead the hu—ous mdteriuls rryuiremcnu under Chapter 695 of We
CnlilamiaVlcolN&Safety Cale,Sections 25505,M533 and 8530.1 undertund Nat
If the haildlbg docs rat curmntly hove a mnunL that it is nsy mspansibilhy m notify the
rccupum of c y Inch muga be met prix to issuvtce of n Cenifcate of
Occa cy'
Ow ruwhcris. m Dae TOTAL: ISSUED BY:
OFFICE