24552 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HU ILUI G•RLRCTHICAL PHRMVI'NO.
APPLICATION/PERMIT PLUMBING•MECHANICAL 24552
BUILDING DIVISION HUILDINO PROJECT IDENHEICATTON
BUILDING ADDRESS:�l� ( � W �A Cr UNITp 1,01'k SANITARY NO. APPLICATION SUBMITTAL DATE
10
OWGG//N//••��E�'R NAMP �er I PHONE: CQy1jtQ OR'$NAMI!: /1_ �Si ,n.l, p�` � OL#
l/J',l�w\ [(NAI /W/1 s 11 (/ N/C CONTROLp
•ARCIIUTCI' 'NG NEER: LIC NO: AUS:rx a _5 5 q Si ojq ❑
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PIiRMIT'INPO
1 'S 1 LEG ILECf PLUMB M
N 1 , .1 `� PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RMIDENTIAL
G1 ISCJRyOO
Cz Iherebyafflonthmm
lamlicensedundcrprovisioofatiprerit commencing with D
Ce
ON
[r102 Section 7IXX1)ofDivisionJn(Nc Business std Professions Code,and myliceme is in PANELS
Cu full forceand c"'13-1
fea �l y UPT02MAMPS
azps License �( Lic.M J
oo 6 L Date Cantractmr 201-10(10 AMPS
Fyen ARCHITECTS DECLARATIONOVEN Put AMPS A
SQ.IT.FLOOR AREA $/SQ.FT.
OZ—❑
ZOw'Q Iunta
dersnd leyplamsshall be nulwi,iblic records.
r,4 t JNS ELECTRICA.
Licensed 1'rolessinnxl SIG
5y W F U OWNER-BUILDHR DECIARATION P,CI CRC '/ C.
yx�d Ot1I Imrehy alllrm that I am exempt from the Contmmor's License Law for he
W��m following reason, 7031.5.Business and Professions Code:Any city or coo E 1' ON 1'OL ST'.
which rcyuirca a permit m conshucL niter,improve,demolish,or repair any smuctu
Irs, prinrmitsissuunce,nlwrequircnhe upplicom(or such permitmfilessignWsmleprom I!R DGVICIiS
mL' O0 that he is licensed pirminam the provision ofthe Contmcmra License Law(Chapter
�• 0� 9(commencing with Section 7010)of Division 3 ofthe Business and Professions Code) SWIMMING POOL :[. 2 IC VALUATE N
ler that he is exempt and the basis for the alleged exemption.Any violation of OU'1'LLefS- WIT iPS-
Y Section 7031.56 applicant 5 FIXTURES
y any app icon permit subjects the applicant m a civil Penalty of O M
9 ce not mom thw five hundred Jollnrs(8500). NEW RPSIDENTIALELEM S .PT. �/{/
yCm ❑ LMnwntto0hepropmy,ormyemplayeeswlNwcilforssio(See.compensation, Q STORIES TYPE CONSTRUCTION
3. will doumviumk,unde: mm�urtisoatinmmdedorovdoessnetno ec.on sm Business
and ery whions Cade:The Contractors License who Low dos not apply 1f an owner or
property whohuildsorimprnves thereon.anJ who doeazuchwork himulfarNmugh his mOCC GROUT' RFS.UNITS
employeen.providedthm mua
such improvecnrenot intendedorof(card forsalr If.
own
however,the building mrimproveem is sold within one year of completion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthe Pmpeny,amexelusivelyconv tingwithlicensrd..tonm QTY. PLUMBING PERM[ FEE ROOD ZONE AYN
co®tmct Ne procic (Sec.7044.Business and Praf asions Cale:)The Contmnor's
License Lawdoes not apply 10 an ownerafproperry who buildsmimprovestherean,and PERMIT ISSUANCE;
whocomrdcts for such projects with a contractor(s)licensed purauaattothc Contrucmr's pLTF:R-DRAIN&VI!NT-WATER(PA)
sFEE SUMMARY
License Law.
❑ml am exempt under Sec. ,H&P C for this reason BACK ROW PROTECT.DEVICEO F,DL .S
SANITARY Y N
Owner Date RECEIPTa
DRAINS-BOOR.ROOF,AREA,CONG.
WORKMAN COMPENSATION DECLARATION SIC T'AX Y N
Ire'Co of float thus 1 havoc ortiflcmeie copy then of(Sceure,mit coni Ecalech RF.CEIPI'p
(ers al Compensmlon Insurance oracatifeA copy theroof(Seo.Jg00,Leb CJ which PIXTURRS-PI!R TRAP ARK PEE Y N
vers all court�rGx1mJentlyy(�npi6
Policy p s/s` GAS-EA.SYS'IRM.I INCDIVISIONILETS BUILDING DIVISION FE S
b`, 1IDD UU 11L0� ll 11
Compun)
❑ CcnifeA copy is- . sh GAS-HA.SYS'T'EM-OVER4(EA) P CI1I!CK PEE
ohcrchy famished. b
IIrCerdfed copy is filed with Necity inspection division. GRBASIVINDUSTRI.WASTE INI'ERCHVI'OR GRADING FBI,
CHRIHECA'I'1!OF EXEMPTION FROM WORKERS' GRCASBTRAP SOILS ME
COMPENSATION INSURANCE
(This uctiannend na be completed ifthe permit is poison hundrWdo11ars($100) SEWER-SANITARY-STORM PA.201 ENERGY FEE
or lees.)
I ceni(y Nm in the perfamance.fine work for which this pcnnit is issued,Ishall WATER HEATER W/VENT/ELECIR
not employ any petvm in any manner so as to become subject to the Workers' PAID
z Compenxutimmlownd Cnlirnmie. Date WATER SYSTEM/IREATING Data Receipt4
Applicant
20 NOTICE TO APPLICANI'.If.after making this Certifcamof Exemption,yousbould NEW RESIDENTIAL PLACE. SQ.FT. TOTAL
r 'Abesnmeaubjecnnthe Wmkds Compemmiaa Provisions of the Lothar Cade you must
� > forthwith comply with such Provisions or this permit shell be deemed revoked. BUILDING FEF.
4 [� CONSTRUCHON LENDING AGENCY SEISMIC FEE O
Vz I hereby afflrm thatthem is a construction lending agency for the performance of
O work
Leaders;
for which this dt�c.31197,Civ.CJ TOTAL: HLECIRIC FEE
Namc
Q U Linchn.Addte•. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I has read t ie application and stale that the above information is
t" W correct. I agree to comply with all city and county ordinances and state laws relating m PERMTI'ISSUANCE
MECHANICAL FEE �s
t.. y building construction,and hereby aurhmire representatives ofthis city to enter upon the
V Z above-mentioned property for inspect ionpu s. ALTER OR ADD TO MICH. CONSTRUCHONTAX
&jdgmedn1, ,,c.,
fa���
d le
e armless Ne City of Cupcnino against �_
liabiAIR I[ANGLING UNIT(TO 10,000 CPM)
in co
AIR HANDLING UNIT(OVf!R I(I,IXIO CFM)
Slgnamm of ApplimmUCnnt or Date EXI TAIL ST IIOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE IB;A9'ING UNIT GO 100,IN0 BTU) Date Receiptp
Will the upplicam or future building occupant stmo m f endle haamdaas material I1EA'1'ING UNITOVER IIIgW0I1TU) 1.:
as defined by no,Cupertino Municipal Calc,Chirpier 9.12,and the Health and Safety
Code,Section e)7
ElyYc.a ❑No
VENTILATION PAN(SINGLE RESID)
es
• Will tair co icanmrfumte huildi d by the Bay Area Air Quality Management
BOILER.COMP(JHP OR 1010,000 BTU) ISSUANCE DATE
nmsrdous air comamineme as defined by the Bay Area Air Quality Management BOILER-COMP(OVFJ2 I00,010 BTU)
District?
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT. [3 B
1 have read the haemdous materials requirements under Chapter 6.95 of he 1
California Health&Safety Cale,Sections 25505,25533 and 25534. 1 understand that DEC
if the huilding does mot cunen0y have a mnemt,Nat it is my responsibility to notify the ����
eccupaat of the mquiumcn,a which must be met prior tat issuance of a Cenificme of
Occupancy.
Owner riu
or authod agent Date A / ISSUED BY' ITIrIVaa
OFFICE