24703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
kRCHITECPAINGINEM:
PERTINO + DDI G- .LEC BICAL PERMIT NG.
DIVISION APPLICATION/PERMIT PIN PRODMBING ntRCxnNlcnl. n /I O
4
I{f111.I11Nf,PROJY.0 ADEN'IIFICATION L 4
SS: SANITARY NO. APPLICATIONSUSUBMI'II'AL DA'I'S
s� O V .J `/7 �✓ UNIT# I.0'1'# '
- PHONE: CO
T E �s'r 33s'6 NAC toNlRo #
NEER: - LIC NO: ADDRESS LW Q rC ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
' BLDG bid: PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
cmz Ihereby affirm that l am licensed under provisionsofCTapter9(commencing with
PIC)0Section7")of Division 3 of the Business and Professions Code,and my license is in PANELS
full farm and effect.
aN1zW Liconsn Class — Llc.4 .��9783 UP TO 2011 AMPS Iti
0h Connector 206-IOW AMPS 5 IT.FLOOR AREA S/SQ.IrI'.
f— ARCHITECTS DECLARATION Q� '
Z00Z—1Z I understand my plans shall be used as public records. OVER Ifl(NI AMPS
W.] SIGNS ELECTRICAL
Qy:q Licensed Profemio..I
e�N OWNER-BUILDFR DECLARATION SPECIAL CIRCUIT/MISC.
.�06U 1 hereby art!,.That I am exempt from the Continuities License Law home
W3Ot�i3 Wlowing rmson.(Smminn]03 L5,Business and Drnfensimrs Cndc:Any city or mum, TEMP.ME'rIR OR POLE INS'1', t L E D
J6 which requites a Ixnnn to construct,alter,improve,demolish,or repair any structure M1]_� A
m}� to its issaancuals.m thea Liam for such nn file a signed statement POWER DEVICES �V
ttyy prier quires pp pemti gn
tyC00m that misnlicensed withSction7the Provisions nf the Convenors License Lawions Cuter i
dXCLL 9(commencing with Section]OOU)ofDivisionlo(rhe Business and Professions Code) SWIMMING POOL ELECTRIC t 'PION:
Wry or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURKS
GSection 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
not more than fine hundred dollers($SIg). NEW RESIDEN'I']AL BLF;CIR _ .FEL
p ❑ I,aeownerof theprnpeny,nrmycmployees with wo,uria mi... cnmpensatinq PE CONSnRl1CT10N
I
will do the work,and t he structure is not intended or offered for sale(Sec.]044,Business
and Professions Core:The Cwam cac a License law does nor apply to an owner of
property who builds or improves rhermm,and who does such work huredf or through his
Iown employees,provided that such improvements are not intended or offered for sale.If, OCC.GROUP RFS.UNITS
however,the building or improvement k sold vithinone yearof completion,tbeowner.
builder will have the burden burden of
proving that he did nor build or improve for purpose of TOTAL:
( sales).
'❑ I,aaowner of dto property,aim exclusively mmmctimg whb ascii immmorsm QTY. PLIIMBINGPERMIT FEE FLOOD ZONE MIN
f instruct the project(Sec.73 ,Business and Professions Cndo:)The Contractor's .'
License Lewdoes not apply to an ownerofpropeny who buildaor improves thereon,and PERMIT ISSUANCE
who contracts farsuch projects with a contractors)licensed prrium othe Contnemre ALTER DRAIN&VENT-WATERER
License law. (' ) FEESUMMARY
❑-1.m exempt under Sec. ,B&P C for this..an BACK PLOW PROTECT.DEVICE D•FBE$
SANI'T'ARY VN
Owner - Dom DRAINS-19.00R,ROOP,AREA,CONU. RCClill'Tp
WORKMAN COMPHNSA IONDECLARAnION SQI001,'I'A% V N
f❑ Thereby affirm End lhave
ricane t ccmmof corsent to self-insure,pytherof(Sm.380r Lab C.)ate of
which FI%TURPS-E'ER TRAP - RECEI1TN
Y Workerc'Cnmpensetinn lnsumnce or ecenified copy thereof(Sm.3800,Lab CJ whish PARK PI3E Y N
covers,all employm's under this permit. GAS-EA.SYSTEM-I INC.4 OUTUE1'S �� RECEIPTp
_
Policy BUILDING DIVISION FEES
Company ' GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Cathed copy is hereby famished.
AE Certified copy is filed with the city inspection division. GREASEANDUS•IRL WASTE IN'I'1IRCEPTOR GRADING FEE
CHIT IIICATE OFE%CMPIION FROM WORKERS' GREASE'IBAP _ SOILS PI31i
COMPENSATION INSURANCE
(This section need not becompleml if Ne permit is for one hundred dollars(SER) SEWER-SANITARY-STORM PA.200PT. ENERGY ITE
or less.)
Icertify that in the pertormence of the work for which this permit is issued,l shall WATER Ffli, I ER W/VENT/ELECIR
notemploy any person in any manner so as to became subject m the Workers' PAID
Cnmpms'arinn Laws of Glifnmin. Date WATER SVSTEMOREATING Use Rcecipr#
O z Applicant
z O NOTICE TOAPPIACANT:If,after making this Cenlftcam of B.croption,you should NEW RESIDENTIAL PLMIL SQ,FI'. TOTAL:
E^ ^ IKcome subjecrto the Workers Compensation provisions of the laMr Code,you must
� > fnnhwirh mmply with such provisions or his permit shall be deemed!revoked. BUILDING FEE
nLnkl [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
.z I hereby affirm that there is a construction lending agency for the performance of /x
.0 O the work for which this permit is issued(Soc.309",Civ.C.) 'f0' ELECTRIC FEE
{l. Lender's Name PLUMBING HE
Address QTY. MECIIANICAL PERMIT FEE
U I unify that 1 have rand this application and state that the above information is MGCI IANICAL PER mrect.Iagree rnmmply with all ciryand county onirencesand state laws odiam,m. PERMIT ISSUANCE
building construction,and hereby atnhoriee representatives of this city to enmrupomhc CONSTRUCTION TAX
V7 shove-memi,ned property for inspection unposex. ALTER OR ADDTO MF.CH.
.7 (We)agree to save,indemnify and keep harmless the city or Cupertino against
I'nmbi111ies,j.dgments,cosrs and oxponew which maty many wayninm ugaiav,uid City AIR II AN DI.ING UNIT(TO 10,100 CFM)
Inc.nsrqu nc the grant of lhisp _
s AIR HANDLING UNIT(OVER IO,M10 CPM)
a - 3
Sign rem
are of ApplicampContcr Dare L%HAUST HOOD(WNUCI) PAID
' HAZARDOUS MATERIALS D(/CLOSURE HGTING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupcn'mo Municipal Codc,Chapter 9.12,and the I Icalth and Safety HEATING UNIT(OVER IOO,IX10 BTU) TOTAL:
Code,Section 25532m)t 1
VENTILATION FAN(SINGLP,RI?SID) ��
EI Yea ❑No
BOILER-COME'(311P OR 1 W,IXq B9V) ISSUANCE DATE
Will theapplicant orfuturebuildingoecupanr useeyuipmenr ordeviceswhichemit p pp��
hazandous air contaminates as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IWpp��,DWBTU) I` A I D
District?
[I Yes ❑'IN. NEW RES]DEN'UAL MECI I. SQ.FF. -
L have read the hazardous materials ox,mmmmts under Chapter 6.95 of the JAN 27 1993 .
., California Hedhh&Safely Code,Section.25505,25533 and 25534. 1 understand that /s
ifthe building does nm currently have.mount.Ibut it is my resM .fa
rnsibiliry rrmily the - CI QI
occupant of the vacationer.which mint be,met prim Int issuance of a Cenificam n( V Qf L-T11 IH V
Occupancy. .1��//��/�/
Owner orou0orized agent Date TOTAL: ISSUED BY .
OFFICE