24579 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HU 11, ING-ELLUDRICA1. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT rLulMBmc-MEcunNICAI, N G''#�l / J n /I C 7(]
IIUILDING 1'ROJF.C'I'IIIItN'T1N'If.A'1'IO
BUILDINGADOR S: SANITARY NO. APPLICATION SUBMITTAL DATE
4Y/22q waI I UNITp A LOT
OrRNA rV N[ OaD �� P pp� _qCONTRACTOR'S MI?: LIC NO: VVV
V ,�/ NIC CONTROLp
ARCHITECryENGINCER: LIC NO: ADDRESS:` ❑
CON ACI'' PHONE:
Ili L/ �Q / Q QTY, ELECTRICPERMI'I' FEE uuulxxx BUILDING PERMIT INFO
�W 5 ��/ 9G Od.9 PERMIT ISSUANCE �. 'L� PLUM�_B MLCH
LICENSED C TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. //1"➢O--B'GD"ESC PI'I�ON /�`�I'_1.
pyy I hereby affimvhat I am licensed underprovisionsol'Chaprcr9(commencing with 2
iUCO 9ectinn9000)of Dividon3of rho Buslnexs and Prole ions Code,and my license is In PANFLS
1;-VE fan force and W.I.
Fz' License Clan Liaa UPT0200AMIsS
m Q y Date Contmcmr 201-1000 AMPS
,T yet ARCHITECTS DECLARATION OVIiR IOOOAMPS SQ.FT.MOOR AREA ¢/SQ.FT.
OZ—. undemm�J my plansshall he used us publicrecords. T /�, ® a I
gy�J Licensed ProfeWond ud SIGNS ELECTRICAL G 1 g—� ;;II l `'�
Kyec6 OWNER-BUILDER DECLARATION SPECIAL CIRCUMMISC. A+ I� n Lha 11 p 11
OiF 1 hereby alarm that 1 am exempt from the Contractors License law for the ( M II U tl^
m�+u+ EF
w following rcawn(Seaion 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
fS"g whichreyuiresapermitmmnsWa, her,improve.demctish,orsepmrany someoe
;!IY� Fourth its issuance,dso reuine,heapplicam for such permit mfileesigned statement POWER DEVICES DA E
p�j a Oz Ihat he is licensed pursuant to the pravisio a ofthe Contractors icense law(Chapter
4 eLL 9(commencing with Section 7")of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUAT
y �y ortha he is exempltherefmm and the hasisfnrtheildino l eaemptism.Any violationnf
QSection 71131.5 by any applicant fora peemit subjects lM1e npplicammacivil penalty ofOil'T'LETS-SWITCIIFS-FIXTURE'S 8 O��\
gtmore than five hundred dollma(S50B. v ace'--
W m pe I,asownerofthepmperty,ormyemployecswithwagnau irwiccompcnutim. NEWRESIDFNI'IALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
a3- othevorr d the 6fracture is not lntendedor Offend far We(Sec.701 Business t
and Professions Cole:The Contractors License Law does nut apply to an owner of
property who buildsorimproves thcreomand whodoasach work himself or thmughhia
employees,pmvidWlhatsuchimprovementsamnotlntendedarofferedfmsale.If, OCC.GROUP RFS.UNITS
however,the buildingorimpmvement issold withinone year ofcompletion,theowner. /
builder will have the burden of that he did n d build at int for f L
proving prove purposes
ale.).
❑ I,ax nwnerof rhe pmpercy,xmexclusivdy contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7144,Business and Professions Code)The Contractor's
License Lawdoesnot apply to anownernfpropeny who builds orimpmvn thereon,end PHRMI'FISSUANCE as,
who contracts foothill projects withaconlnct.n.)licensedpursuenno the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ lamexemptunder Sec. ,B&PC for this reason BACK FLAW PROTECT.DEVICE TSID:19sE
SANITARY Y N
Owner Dare RECEIPT#
DRAINS-FLOOR,HOOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihemhyoffirat lematibmnhave
rance or
ineateofwnxmcreof(to insua,aracen.)which Fl%TURFS-PF.R TRAP RECEIPI'a
Workeallempheyce'suderthis eoracenifiedcopy themnf(See.3800,f.ahCJwhich PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Polity# BUILDING DIVISION F[ES
Company GAS-EA.SYSTEM-OVER 4(FA) PI.ANCUECK FEE
❑ Cenifiedcopyisherchyfumishcd.
❑ Certified copy is Bled with theedy inspection division. GREASFANDUSTRL WASTE,INTERCEPTOR GRADING FEE
CERTIFICATE OF IDHMPTION FROM WORKERS' GRFASETRAP SOILS(Tilt
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is Forane hundred dollms(S IW) SEWER-SANITARY-STORM FA,20011'. ENERGY FEE
m less.)
I cenify that i n the performance or the work for which this permit is issued,Ishall WATER HEATER W/VEN'/ELF,IK
not employ any person in any manner In as In a Sasy tSLe Workers' PAID
z
CompensationI.�fCdifo Data Z WATER SYSTEMOREATING Dare Receipt#
is itr 1-e a
OQ NOTICE TO APPLICANT:If,after maki �s am
of Exemption,youshould NEW RESIDENGIAI,PLMH. SQ.FT. TOTAL:
�+ fn become subject to the Worker's Compensation provisions ofthe Labor Cede,you must
�rforthwith comply with such provisions or this permit shall bvo
e deemed mked. BUILDING FEE
0. F) CONSTRUCTION[.ENDING AGENCY SEISMIC FEE 0�.+
V z I hereby affirm that thea is a construction lending agency for the perfomance of
O
the work for which this Permit is issued(Sec.3009,Civ,C,) T ELECTRIC FEE f
Lender's Name
0 lander.Address QTY, MECHANICALPERMIT FEE PLUMBING FEE
I sentry that I have hand this application and said that the above information is
0.I coned I agree to comply with dl city and county ordinances and stem laws relating m PERMIT ISSUANCE MECHANICAL FEE
y building constmnion,and hcrsbyahar
wize represenmnt
tivesofthis city to eerupnn the CONSTRUCTION TAX
U 7 ubwe-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
•7 (We)agree to save,indemnify and keep harmled,the City of Cupertino agenda
luddlities.judgrourn.costs andexpenas which da y wnyaccrueaguinst said Ci AIR HANDLING UNIT(TO IQIMMI CFM)
;Mf(the ring of this pemril`
n se0lyencep :4M,A del � AIRIIANDLINGUNITOVF.RIggp C'FM)
a`J(/L
Signamreof Applicant/Contractor Date EXI IAUST 11000 IW/DUCT) OvRb PAID
HAZARDOUS PATERIALS DISCLOSURE HEA'L'ING UNIT(TO 100,WI)BTU) Date Receipt#
Will the applicant in,future building occupant store or handle havMme,materiel fIEA9'ING UNIT(OVER 100,000 ETU) TOTAL:
as defined by the Capetian Municipal Code,Chapter 9.12,and the health and Safety
Code.Section 25532(e)'!
❑Yes ❑No VENTILATION FAN(SINGLE RISID)
equ
ch
Will thI,corcantlirfamrt buildings by the Bay Ana A<nmuality Man igeemit
BOILER-COMP DIIP OR 1011,000 BTU) ISSUANCE DATE
hazardous air conmminums n defined by @e Bay Arta Air Quality ManagementBOILER-COMP(OVER IW,00081'U) B
navies'! n
❑Yes 0 N NIiWRESIDENTIALMECH. SQ.In'. ��OV 09 p99�
I have rem
rend he hardmas materials ounihamcnu under Chapter 6.95 of the '!!
California Health&Safety Cede,Stoma 25505,25533 and 25534. 1 understand that ser
if the building does not currently have a tenant,that it is Illy respanihi lity,m notify the V wt-till
occupant of the requirements which must bm e met prior issuance of a Certificate of
cupancy.
Ownerm.dthonzedT 9 ageh Date ISSUEDBY:
OFFICE ,�-