24971 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "LJO, Nr:'nta?CTRTCA, PERMITNO.
APPLICATION/PERMIT PLUMtlING-MRCHANICAL /� /1 ��^j
BUILDING DIVISION 1 110 Bull DING PROJECT IDEN'IIFICAI]ON LL(• 1
BUILDING ADDRESS: 11'' ���('�� ` /����)� tL_ /-rl gTSl/ rf71stlD - SANITARY NO. APPL'ICATIO'N SUBMITTAL DATE.
.. K Uf�� • ' u� 1 UNITX^ !''O'l'�J�/�^�-'LO�1JX V
� &IiR AME: PDO ' CONTRACTOR'S NAME: LIC NO: NIC i CONTRO`Lp
MI Ib ''/ENGINEER: LIC NO: ADDRESS:
J'( ❑
'o�h{TAQLa 'l mar"
PHONE: QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
f 1 - y/1 I'Lie r a li LDO ELECT PLUMB MECH
J PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL POB DESCRIPTION
cy.Z 'I herebyaffiml that l am licensed underprovisions ofariplv9(commencing with
POC Section 7000)of Division 3 of the Business and Professions Cade,and my license is in PANELS
ty�1E full force and effect '
Dam Cnnvacmr UP T0200 AMPSFZyl v t.Qyns c
w 201-UXXI AMPS
�
V
Z O,z' ARCHITECTS DECLARATION OVER 1060 AMPS
SQ.IT,FLOOR AREA $/SQ.FT.
I OZ�n I understand my plans shall be used as public records.
f.vs SIGNS CLE CAL /
Qk Licensed Profcssionul r n rs. R1
CKte. en Iam-BUILDER DECLARATION ON SPEC LCIR 1 PSC. '
�A4'06U 1 hereby affirm thm I am exempt from the Contractors Licence law for the
following mason,(Section'l03 1.5,Business and Professions Code:Any city MP. OR POLE INS e 1 I t -� ( d gl'K•
F which requires n permit m constmn,dme improve.demolish,n mIn. a y s co m
primr(olls iswunce.also myuires the uppliwm femch pemdinofileaeign m t PoWER DEVICES
n _
that he is licensed pursuant the provisions of the Contmis udLicca
a o�' o
9(commencing with Section 111D)of Division 3 ofthe Business and lass ens er SWIMMI
%appo)(5knific DATLUAT
_m
or he is exempt therefrom and the basis for the alleged exemption.Any v lationof O CHER- ES
aSection 7031.5 by any applicant for ape.it cubjectc the applicant toe civil achy of
❑ not mare duan five hundred dollars(5500). RESIDE EI.ECIR S .FT.
ElI,asownerofthepropeny,ormyemploytts with wages astheirsolecompemetion, Q STORIES TYPE CONSTRUCT ION
m3— will do the work,and the struamreis unlamented proffered forsale(Scc,na4,Business
and Professions Cade:The Contractors Li«nu Law does not apply to an owner of
property who builds orimprovesthereon,and whodoessuch work tonsdfanhroughhln OCC GROUT' RCS.UNITS
own employees,provided thatnuch improvements are not i mended oroffered for sale.If,
however,the buildingor improvement is sold within one year of completion,the ow TOTAL:
huilder will have the burden of proving that he did not build or improve for purpose of
sale, QTY, FLOODZONIi
❑ Laxownerof the property,am exdusivelycrmtrading with licensed contmcmrslo PLUMBING PERMIT FEE APN
construct the project(Sec.704W,Business and Professions Cede:)The Convector's
Licarselawdcesnotapplylosnownerofpmpcny, who builJeorimprovesthereoo,and PERMIT ISSUANCE
who contracts fnrsuch projects with aamtractor(s)licensed pursuant to the Contractor's
Littnx law. ALTER-pRA1N&VIiNT-WATER(EA) FEE SUMMARY
❑ In exempt under Sec. ,B&P C for this carbonBACK PLOW PROTECT.DEVICE IJI'SID:FE:S
SANITARY V N
Owner - Data RECEIPTp
DRAINS-FLOOR,ROOF.AREA,GOND.
Opl",Iry
fy WORKMAN COMPEcam o1 ON DECLARATION SCHOOL TAX Y N
P{I bemby affirm that 1 have a certa cad ie copy th m.f(Seaore,m a ab C.)which RECf:IPf pFIXTUNIS-PER TRAP�hkum'Compenemlan lnsumnce nrattnified copy thereof(Bea.3800,Lub CJ whish PARK IEE YN
Pyp . RECEIPTMGAS-LA.SYSTEM-1INC.40UTLETSX BUILDING DIVISION FEES
Company GAS-ISA.SYSTEM OVER 4 PEA) PLANCHECK FEEL
❑ CertilieJ copy is hereby famished.
❑ Certified copy is riled with the city inspection division. GREASEnNDUSDU_WASTE INTERCEPTOR GRADING FEE
CF,RTIFICATB OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
_ (This section need not be completed i f the permit is for nnehundrcddoloce(510() SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
to lass.)
I century that in the perrarmance of the work fm which this permit is issued,Ishall WATER HEATER WNENTRiLEMR
not employ any person in any manner at as to became subject to the Workers' PAID
Compcnsationlawsof California. Data WATER SYSTEM/TRFAL'INC part Nrccipt
0Z Applicant
z C) NOTICE.TO APPLICANT:IL after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. OTAI::
F` fn become subject to the Worker's Compensation provisions ofthe Labor Cafe,you must
� ; forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING PEE
aQ CONSTRUCTION 1.MNDING AGENCY SIdSMICFHR
Uz I hereby afrnar that them is a construction lending agency for the parfomance of TOTAL ELECTRI
O the work fur which this Permit is issued(Scc.3097,Civ.CJ
Lenders Name PLUMBING ij;
Lenders Address QTY. MSCI IANICAL PERMIT FEE
V 1 certify that 1 have read this application end smm that the above information is
.coneel.(agree mcnmply with all city and county orJinenttsend stale laws relating to PERMITISSUANCC MECHANICAL FEF ,
VE-' y building soreaudlon,and hereby imhnrim representatives ofthiscity to enter upon the CONSTRUCTIO AX
ahove,mentioned Property for inspection Furrows. ALTER OR ADD L'O MECH.
(We)agree m savq indemnify unit keep harmless Ih Pty of Cupertino ngainst
Iiahilum"'udgme stiar'ddexpert awhichmayinm w az/que�ager tsrid City AIR HANDLING UNITUO I0,0WCFM)
me dT row re anA \fl'.permit /� AIR HANDLING UNIT(0VER 10,(100 CFM)
Signal riof Applies A gr�ucltor ✓`J� Dme EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEALING UNIT IT01X1,00(1 BTU) Dam Receipt#
Will the applicant or futim building occupant store or handle hmardaus materiel HEATING UNIT(OVER 100,(X10 B'lll) TOTAL:
as defined by the Capeniro Municipal Code.Chapter 9.12,and the Health unit Stay
Code,Scotian 25332(u)'1
13 Yoe ❑No VENTILATION FAN(SINGLE REBID)
' N'ill th<upplicanwrlmure M1uildingoecupunt useequipmemordeviceswhichcmit
BOILER-COMP(3I IF OR 110,000 BTI) ISSUANCE DATE
husmdmis air conmmionnm as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER UM000 BTU)
natnw
f!`( ❑Yea ❑No NEW RESIDENTIAL MFCH. SQ.IT. p�
]@4 1 ��� 1 have cad he hmnmmPAIammals ammmals rogdo on.under Chapin 6.95 of theVail V
` 'Califomin l lealth&Safety Code.Sections 25505,25533 land 25534. 1 underswnd that
if thebuildingof the es not requirements
which
mhave ust
he that it my respn a of
to inion the �� ��
occupant of the requirements which must he me prior to issuance of a Celilwic of PR
Occurymcy.
Ownenn amborired agent Data TOTAL: ISSUED BY: