24633 MAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL _ 4 3 24633
N /I �IN'�
:i:iKsiST:'Lr-r BUILDINGPRGJECr IDEB nMCATION,',:#'},,:"?-�:':( L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMOTAL DATE
n
/ 0� 4UNII'a LDTp 2--le
� L—
OWN- SNAME: r PHONE: CONTRACTOR'S NAME: LIC N
Q M U: N/C CONTROL.
RCHITECT/ENGINEER: G P LIC NO: ADDRESS: El
CONTACT: PHONE: BUILDWG PERMIT INFO
QTY. ELECTRIC PERMTT; ` .' .` FEE '
BLDG ELECT PLUME MECfI
PERMIT ISSUANCE ❑ El ID ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DE CRIPTION
=CZ I hmrbyaffirm that lam Bice.mdundmpmvixmm,.Chapter9(commencing with n
Lk711) � Cf '���
=00 Section7Of Division 3 oftbe Business and Professions Code,ondmy license is in PANELS /-• /7
J 6 furl farce and effect 4 �J
-Zy nom re Cl;s - Lic.a /23 -).Z0 UPT02MAMP$ �/'or+a Shori� e/'L
-<y Date C.ntmaor //�-='/•�J• 201-I"AMPS
SQ.FT.FLOOR AREA $tNQ.FT.
-mZ ARCHITECTS DECLARATION OVER IBOB AMPS r
y 1 understand my plans shall W used u public records. g••�
;E� Licensed Profnwional SIGNS ELECTRICAL L II p N
%p6 OWNER-BECLARATION SPECIAL CIRCUIT/MISC, f-� r ^ l✓w
-6t- 1 hereby off that 1 am exempt
cmpt frfrommNe Contractor's License law for the V—! uU 1Y
Orn following reason.(Section 703 L5,Business and Pmfexsians Code:Any city m county TEMP.METER OR POLE INST.
-y whichrcquima a permit to construct,area improve,demolish.or repair enY sweture w T
'?} prior tons iasuence,alsnrcquires theapplicant for such pcmd0.fileesignW summem POWER DEVICES Al
5Mp0 Out he is licensed pursmnt to the provisionsoffle Convacmr's License Law(Chapler SWIMMING POOL ELECTRIC
-�� 'las—
nocturnal with Section 7000)of Division 3 afthe Business and Professions Code) VA
^y or Beet he is exempt lhercfrem and the buisfor On allegedexemption.Any viohnkm of OVfLELS
-SWITCHES-FlXTURFS � d/�
ZC Section 7031.5 by any spiritual fora pe.iuubjece the applicant,.A civil penmry of �/
.S t nm more Nan rise hundred doll.($500). O
_ ❑ I,asownerafthepropery,armYemPloYceswithweFesastheiruleampcnsation. NEWRESIDEITIALELECIR —SQ.FT. STORIES TYPECONSTRUCTION
3� will dothe work.and the ivucmreianot irmidedoroffeed forsale(Sm.7044.Business
And Professions Code:The Contactors License law does not apply t.An owner of
oweenywhnx,pororimpmvesthcmogandwisuenmch wmk Nnsvelfforsghhis OCC.GROUP RES.UNITS
wt,ever,oyaa,prov ori Thatsuch impmvemrnthtienotne yeaofr moffered for tile.If.
boweer ,will have
burden
fp.enlisut hediinot build of completion,thrower- TOTAL:
builder will have the burden of proving that he did not build.,improve for purpose of _
Able.). 0s• - wsaa,:7•s..;
❑ I.uownerofthe Propeny.em xclasivelY<ontracting with liceneM connectors to QM' �6 t��� 7 �'UWGP'�'/s'YI' `'k' - FlAOD TANE APN
a?n Teia:t.rP3,..A asraa•arzrsnr�rma.ns•z•Lx d,-w.-
c.astrum the project(Sec.7044.Business and Professions Code:)The Co..,.
Lianse law does.cot apply to anownaofproperry weobluldsorimpmves in.,And PERMITISSUANCE
whocanuacts fmsuch prumers with aantaoar(s)ficanud pursuant to the Contractors a .tet - :, are -r
Llaue law. ALTER-GRAIN&VENT-WATER(EA) '' 'y?,S?,'!?FEE SUMMARY,rjlkexAL,
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT'.DEVICE OUTSIDE S
SANITARY Y N
Owner Data RECLPT p
WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR,ROOF.AREA,COND. SCHOOL TAX YN
❑ IhcrcbyaK chair haveeanificate of consentmself-iuurt,oracenifiwte of FfX.IVRES MR•fRAp RECEIPT.
Workers Compensation lnsurana or a certified copy tiaobf(Sm.3800,Lab C.)which PARK FEE Y N
�•'� covers All amp! n this 9e e ,/ RECEIPTa
Policy p p sem✓u-L�/ DLrCI'7 GAS-EA.SYSTEM-1 INC.40IITLEfS BUILDING DIVISION FEES
C°tnParty G 'y! G G""I® GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certifiedcopyahembyfurnished.
Certified copy is fired with the city inspeNon division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTUICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisacetion need not he completed ifthepermit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA.2MFT. ENERGY FEE
or less.)
I certify that in the performance of the want for which this permit is issued,l shall WATER HEATER W/VENIYELEM
not employ any person in any mannor so in to become subject in the Workers PAID
Compensation Lawsaf C.1ifomia. One WATER SYSTENBRFATING Data Raeipta
2 Applicant
0 NOTICE TO APPLICANT:If,After making this Cerificam of Exemption,you should NEW RESIDENTIAL PI.MB. SQ,FT. TOTAL:
UJ became aubjA.,to Ne Workerh Compensation provisions of the labor Code,you must
forthwith amply with such provisions or this paved,shall Wdomed invoked. BUILDING FEE -j
Q CONSTRUCTION LENDING AGENCY SEISMICFEE f
Z I hereby affirm that them is a construction lending agency for lee performance of TOTAL: ELECTRIC FEE
J O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name -
1-` Lender's Address QTY, : MECHANICALPERMIT'.' FEE- PLUMBING FEE
LU co I certify that 1 have read this applicmion and Ince that the above iafarearion is MECHANICAL FEE
rtes l agree to comply with all city and county ordinances and state laws of.unglo PERMIT ISSUANCE
7Authorize c.nstction.end herebv Authoe representatives.(this city to enter upon the CONSTRUCTIONTAX
bo
i Z ave-memi.med property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree a save,indemnify and keep hornless the City of Cupertino against
liabilities,judgmems,c.sa..dexpevs,xhich may in any way ac crue...ins...dCity AIR HANDLING UNIT(TO I0.L'rk9 CFM)
in c.nsequencRQ the reong of this Permit.
//` NBI101
Z- AIR UNIT(OVER I1 CPM)
SignAt omit fApp,icaMConuac l /D a EXHAUST HOOD(WMUCT) 12..Le/�. 7 7�
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TD 100,000 BTU) Dau Receipt At
Will the fla,Calmed.Munbupdi g oexamant Cade,
9..r hanAnd
dle hhBradth and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupeniw Municipal Cale,Chapttt 9.12,and the Health erM Safety
Cod,,Section 25532(.)7
❑Yes 5eo VENTILATION FAN(SINGLE RISID) -
ISSUANCE DATE -
Will theapplicvltmfumrtbuil&ngoaupanBueequipmentaldeviceswhichemit ROLLER-COMP(3HP OR Ilp,000BTU) (µ
Issued.air conit,u defrmd by Osea
Om Bay AAB Quality Management BOILER-COMP(OVER 10 ,wit BTU) I D
DIaAid?
❑Yea NEW RESIDENTIAL MECH. SQ.P'. DEC 18
I have:rtad the harndau materiala requirements under.Ch aper 6.95 of the 1992
California Health&Safety Cade,Sections 25SD5,25533 and 25534.I understand that
if the building does not currently have aremaL that It is my responsibility m pokily Oa GI1 f.
occupant a mlvi.ts which must W tom prim m iuumtce of A Cardinale of - Vf
ISR• Occup Y A /z-/&- 7'L.
i' auUm Aedagent Dale' - NOTAL: ISSUED BY:�f '�� hyr�j'•/'✓
OFFICE