24947 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL. PERMIT NO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL /'N A4 VM 4/\ /I
�DILDING DIVISDIVISIONBUILDING PROJF,CT IVEN'1'IFICATION L
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMfITALDATE
0 2A OVA by UNITII LOT Is
OW :RS NA I°�� PHONE: CONTRACTORSNAME: LIC NO: N/C CONTROLM V
A CIII iCUENGINI?E : LIC NO: ADDRESS: x
CONI'AUTCT; , PIIONIS' Q . ELECTRIC PERMIT FEE
T '
TYBUILDING PERMIT INFO
e 4& li, PLUMB MSCI
PERMIT ISSUANCE
LICI?NSLD CON'I'RACI'OR'S ULCfARATION APPLIANCES-RESID IAL TOB DESCRIPTION
R�y Ihereby afford that l am licensed under provisions OfChapmr9(commencing with ��
on❑ Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
QC V full force odd effect.
yW License Class Lic,N UPT02MAMPS
h Q y Date Conuacmr 201-TOM AMPS
[[--� ARCHITECTSIILCLARA'I'ION SQ.FT.FLOOR AREA S/SQ.FT.
pti OVER II)(gl AMPS
)y_,Q 1 understand my plans shut]themed as public records. 1 ��
_yf—JW SIGNS ELECTRICAL `
Licensed Professional
Yyre6
OWNER-BUILDER DECLARATION SPECIAL CTRCUFDMISC. '-
kOLp., I hereby affirm that I am exempt from the Conditioner License Law for the
Z 3 m m fallowing reason.(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.METIER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
F,y}� pTmrto its issuance,alsomquires the applicant for such pcmauo file a signed statement POWER DEVICES
9(cosn encingwthSuti Tl7")ofvisionim3ofte Busim's Licensemsiom upter
9(cmnmencingwith Section]000)ofDivision3ofNe Busineu end Prmfusiom Coale) IMMING POOL F.LLCfRIC ^ VALUATION
-,y or thin he is exempt therefrom and the basis for the allegeJ exemption.Any violation of U'fLLTS-SWITCfII'S-FIXTUR[S 1 G CV
�yQ
Section]031.5 by any applicant for a Permit subjects the appbicannoaelvilpeuaty01 ` (�
fw not mom than five hundrW do11an(S5ML NEW RESIDENTLALBLF,CTR _SQ,FT.
R in [Iusn
I, wneraftheprnperty,ormyemployeeswithwagesutheirsolecompensation. STORIES TYPLCONSTRUCfION
�} will do the work,andlhe lannotrerUmtimeadedoroffcrdforsalc(S..7(144,Bu5
and Pro@ss ns Cash, a'Me Contzdor's License Law does not apply to sea own"of
propenywhobuildsorimprovesthemon,sndwhodoessuch work himulfor through his
OCC.GROUP RFS.UNITS
employe ,WEsvidea ted.c.ch inrprovcnemrn smenronakdmoffered fmsule.If.
how e,Nebulldingmimprovemem is sold within one ycarofcomplefan.the owner
builder will havertlm burden of proving thin he did not builder improve for purpose of
twnttihe propeny,om exdusivelyaomraming withlicenmdcnmmnonm QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
mtfuct the p ire (Sec.](144,Business and Professions Code:)The Contractors
w i
1 ce seiad«snot apPlytoanownerofpropenywho buildsnrimproves Hereon,and PERMIT ISSUANCE
wbmcanndirs Antioch projects with a commends)licensed pursuant to the Contractors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
—_611131
❑ 1 inSA
n exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE D FI:
NITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIM'q
WORKMAN COMPENSATION DECLARATION SCHOOL.TAX Y N
❑ Ihereby affirm that l have a certificate ofcomem to self-insure,or a certificate of ` FIXTURES-PLRTRAP :CEIPI'M
Workers'Compemmionlnsumnceoracenifiedcopythersof(Sec.38W,Lab CJ which PARK FEE N
coven all employee's under this permit. GAS-EA.SYS'I'l?M-I INC.4 OUTLETS LC M
PolicyM IL 1 NFEES
Company GAS-LA.SYSTI?M-OVER 4(FA) PLANCIiF.0 E
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRANG qiE aa�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This menanneednm 4 completed ifthe Permit is torose hundred drill.(SIM) SEWER-SANITARY-STORM EA.2WIT. ENERGY FEE ..0
orbits.)
I certify that in the pedommnceaTthe work fee which this pemrit is issued,Lsha11 WATER HATER WNENT/F.LECTR
.at employ any person in any manner so as to become subject to the W«kers' PAID
Compensation Laws of Califoram. Date WATER SYSTEM/TREATING Dam
O Z Applicant
Z NOTICE TO APPLICANT:If.after making this Certificate of Lxemprion,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
{^ V] become subject to the Workers Compensation provisions of the Labor Code,you must
fonhwitl5 comply with such provisions or lhis permit shall he deemed revoked. BUILDING FEE ^�
W z affirm
LENDING AGENCY SEISMIC FET?
5 1 hereby arm that there is a construction lending agency for the performance of
V O the work for which this Permit is issued(Sec.3097,Civ.C.) P.LGCfRIC FEE
Lender's Name 0 PLUMBING FEB U Lenders Address QTY. MECHANICAL.PERMIT FEE
1 rectify that I hume read this application and stare that the above information is
4 can.[.Iagt«meomplywithullcityand...roymErranuasndsulelawsrtlmingm PERMIT ISSUANCE 'R MECHANICN,FEE
Lo� building construction,and hereby amhorice mpresentativesofthiscity to enter uponme
V 7 above-mentioaW property for inspection purposes. ALTER OR ADD TO MUCH. CONSTRUCTION TA%
F7 (We).gree m save,indemnify send keep harmless the City of Cupertino agnir w
liabilities;judgments,eotsadeapcnseswhichmayinmywayaccmeagainstuid City AIR HANDLING UNIT(TO IO.WCFM)
in ccracquence of the graining of thisiermit.
AIR IIANDLING UNIT(OVER 10,000 CFM)
)V—e,,;` !� ✓
8' ugof Applicam/Con Date EXHAUSTBOOD(W7DUCID PAID
I IAZARDOUS MATERIALS DISCLOSURE HEAq'INGUNI'T(Tolf)(000BTU) Date FFeipl0
Will the applicant or future building nccupant store or handle harsoll material
in
red ed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I[EATING UNIT(OVER 100,000 BT U) TO]A
Code.Bectinn 25332(a)? VMfILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DA'Z'E
Will rhea licant orfuturchuildin BOIL1?R-COMP(311POR 100,(X)0 BTU)pp g by the
Am.Ain Quality
8
nuzmdoua air conumirmanu as defined by the Ray Arca Air Quality Manegemeni BOILER-COMP(OVER IW,0M BTU)
isms'
13Y ❑No NLW RESIDENTIAL,MECH. SQ.FT, r fp�
Lreed the hazardous materials
reyuiremenn under Chepmr 6.Y5 of the W�� W I��a]I
do"&SaftyCodeSections25505.25533 end 25534. Iundemund thing Aoca nm carrc dy haveam... ......s my responsibilirymnmifyhe ` V dF VUrrnI INU
theod"m mems which must he met prior m issuance of o Crou icam of lhmored agent Dam ISSUED BY:
-— _ OFFICE i
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