24595APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING-hl, CIRI A.
CITY OF CUPF.RTINO
APPLICATION/PERMIT PLUMBING - MECHANICAL '
BUILDING DIVISION BUILDING PROJECT EVENT IFICATION
PERMITNO.
24595
HDILDING ADDRESS
SANI'1'ARYNO.
APPLICATION SUBMITTAL DATE
1LXL ��ff�`/,r!1 y�
1 '� Iv'1� >v U UNIT# LOT#
OWNERSNAiMEE: 1, PHOONE:I CONTRACTOR'S NAME: LICNO:
M IVJ r l� / p m� ��
N/C
CONTROLA
ARCHITECUENGINEER: - LIC NO: ADDRESS: ,� Z
7� I
o�rS T
CON'I'AC'i': PHONE:
' QTY. ELEC'T'RIC PERMIT FEEBUILDING
PERMIT INIIO
BLUG ELECT PLUMB MECH
1.17RMIT ISSUANCE
El El
cry
41LOQ
K �1F
LICENSED CONTRACTOR'S DECIARATION APPLIANCES - RESIDENTIAL.
I hereby affirm that l Am licensed under pmvuiomnfChapter9(mmmencing with
Section]IXIIB�off phs/is�i�onnlSoftire ''B,,umessgu�nit PattaxionsTCondund my license is in PANELS
lull forcc,riul V'TeSla_„n�qq
.TOB DESCRIPTION
La„Z41
N Q d
FON
ZO
OZ-0
Licrnsel UP T021NIAMPS
.i# /�4TI.a�
Cnntraco r 201 - 10(10 AMPS
ARCHITECTS DECLARATION
lunderslandm le 1 Il he rued uv bllm mroMs, OVER IWB AMPS
yp'nsso pu
SQ. FT. FLOOR AREA
$/SQ. IT.
ELECTRICAL
Licensed
ed professional OWNER-BUILDER DI3CLARA'TION SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contractor's License Low for theE
following mason. (Section ]031.5, Business and Professions Cale: Any city or county TEMP. METER OR POLE INS'IT.
which requiresapermiuo conarua, Woe improve, demolish, fir repair any swaum
iormisicensed pinworm th t,neemicumfthe Co permit,, l ictan, Lmv(otement POWER DEVICES '
thinChapter
tiro he is licensed with Ssuaot tolhcpro'Disnsof the Comradorsmid Pro LsimasCde)
9(commcncing with S«tion]000)of Division Sof the Business and Pmfessinns Cade) SWIMMING POOL IiLELTRIC
Q �Q
. O ped• V
i a N
��
a¢p
a6o�'
I
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UTE R
VALUA'1'10
y _y
5�<
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any rppliciomfnrapermllsubject, heapplicunlmncivilpenaltyolOUTI EfS SWITCHES-FIXTURES
CW 12a
2
AdElI,asmwndrmftheproperry,ormyemployeeswilM1
6'i --
not mm a than five hundred dollars ($500).
wagesas Weirsolecompensation, NEW RMIDFNTIN, HLECTR _SQ. FT.
will do the work, and the structure is not Intended or offered for sale (Sec. 7W4, Business
STORMS
TYPECONSTRUCDON
and Pmfessiom Code: The Cerantena's License Law does not apply to na owner oI'
propenywhmbuildsmrimprovesilamon, andwhodoessuch work himselfonhrough his
employees, provided that such lmpmvemensare not itnendedor offered forsale. If,
OCC. GROUP
RIS. ON) IS
however, the building or improvement is sold within one year ofcompletion, the owner- TOTAL:
builder will have the burden of proving that he did nor build or Improve for purpose of
sale.).
❑ I, as mwnermthe progeny. am exclusively contracting with licensed commctors to QTY. PLUMBING PERMIT FEE
HOOD ZONE
APN
manci fire project (Sec. 744, Business and Professions CodoO The Commcmr's
License Lowdoes nnrnpply to w ownerofpmpeny,hobuildsor orproves thereon, and PFRMITISSUANCE
who contracts forsuch Impacts with acontmemr(s) licensed pursuant othe Contractor's
Li.d'c1, v. ALTER EA)
FEESUMMARY
-
_
❑ I um exempt under Seo. 1{ & P C for this reasonBACK FLOW PRO'1'I?C'I'. UIiV ICE
SIDE FEES
SANITARY Y N
Owner Doe
WORKMAN COMPENSATION DECLARATION DRAINS - FLOOR, BOOP, AREA, GOND'
RECMJvT#
SCHOOL]'AX Y N
)❑ I hemby offrm that l have a cenificao ofconsdnt to self answer, or a cenilicam of -
FIXTURES-V[R'I RAP
nInsurancema fietl copy Omrcof (Sec.3800, lab C.)which
•Ween
Compeemployee's
RECIBPIT#
PARK FEE Y N
al rmit.
rs all employee's tinder permit GAS - PA. SYSTEM I INC. 4 OUTLETS
Palicy#
RDC
BUILDING DIVISION PEES
DIVISION
•
Company GAS - FA. SYSTF,M-OVER 4 (HA)
❑ Cenified copy is hereby furoned.
PIANCHECK FEF.
GRADING FEE
❑ Cenified copy is Bled with the city inspection division GREASIVINDUS'IRL WASTE INTERCEPTOR
CER'I'IFICATO OF EXEMPTION FROM WORKERS' GREASE TRAP -
SOILS FEL'
COMPENSATION INSURANCE
ENERGY FEB
(Thiswerimn nee not he completed O the permit is Eocene hundred dollars ($I00) SEWER- SANITARY -STORM EA, 2031FT.
r lcssl
I Oddity that in the perfomucce ofthe work for which Oils permit is issued,I shall WATER HEATER W/VIcNOr.1,ECTR
nmemploy y pe ran in iiiater am a to become subject to the Worker'
PAID
-a Into. FGi It nmm WATER SYSTEWIREATING
Dam Receipt It
z O
(q
�;
_Applira 41
NOTICI'' APPL :ILa m' this Cedificate of Exemption, you. should NEWRESIUENTIALPLMI{. SQ. PT.
becia rtheahu reply a ker's Corpdorias provisions shall frbeLittainciridd Coda.
voked.you muxt
fnnhwlth wmply with rah provisions nnbis permit shell be Accrued rcvaked.
TOTAL:
BUILDING PP.E
SEISMIC ITE
0.
CONSTRUCTION LENDING AGENCY
U O
LUZ7
1 hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3099, Civ. C.) TOTAL:
lender's Name
HLECTRIC FEE
PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
I cedify that I have read this applictionn and plot, that the above information is
correct, Iagrceu, carmply will, .11 city indcmumy ordinuneesand smte lime"elmal, to PERMI'1'ISSUANCE !
MECHANICAL FEE
r
U
building construction, and hereby aammdm representatives ofthis city mender upon the
aMwe-mentioned popery for inspection purposes. ALTER OR ADD TO MECH.
CONSTRUCIONTAX
(Wo) agree to save, indemnify rami keep homeless the City of Cupertino against
liabiliI..,a enrs,cosuanJ expenses which may in any way accrue against said Chy AIR HANDLING UNIT (TO I ILIO CFM)
'
inconseque eofl grantin flh' nail.
AIR HANDLING UNIT (OVER IQO(p CPM)
2-1 -
PAID
, gra fApplica' a” r Date EXIIAUSTHOOD (W/DUC'1)
AZARDOU II TVR[AM DISCLOSURE HEATING UNIT ('I'0100,000 BTU)
Dae Receipt#
TOTAL.
Will the applicant or future building occupant store or handle hrsurlons marcrial fIHATING IINIT(OVI3R IW,0008TI1)
as defined by the Cula d rev Municipal CSW,, Chapmr 9.12, and the Heahb orad Safety
Code, Section 25532(a)P
❑ Yes ❑ Na VEM'I ATION FAN (SINGLR RESID)
ISSUANCE DATE
BOILER - COMP (31{POR IIN),01M BTU)
at
Will the applicant orfmus buildg
nBayAuipmrnt
by heMannichemir
tiarardous air comominants as defined by rhe Bey A. Air Quality Manugemetn
Quality
District?] BOILER-COMP(OVER 100.0M BTU)
-
p D
IfPf � M
❑ Yes ❑ No NEW RESIUEM'IALMECH. SQ.1rp.
-
1 have read ,he hamrdous mamr ills requirements under Chapter 695 of the
Culifnddu Ileullh & Safety Cnde, Sections 25505, 25533 orad 25534. I maham and War
DEC 11 142
my rsuancsiof a Ci tidiest the
occupantof the onquire eats l whichmustnth, et prior
Occupant of the reyuiremenu which must be met prior to issuance of a Cdnifiarc of
CM To- (.lam
Occupancy.
T �✓�r,��l.
V.
ISSUEUBY:
Owner or uuNoriud agent Dam 'r'TA �
OFFICE