24456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-h;l.Ef:"I'RICAI. PERMIT NO.
APPLICATION/PERMIT PLUMBLNc-MECHANICAL 24456
BUILDING DIVISION BUILDING PROJECTIDENI IF'ICATION
BU ILDING A DURESS: /a�/� � SANITARY NO. APPLICA'DON SUBMITTAL,DA'IF,
AP 0UNII'a COI%
OW NA I PHONE: C ACl'QR:S NAME,: ` LIC NO
B _}NIC` CONI'HOLp
1`11 L NGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMITINFO
QTY. ELECTRIC PERMIT' FEE
Bf.W ELEGTPLUMB MF,CFj
PERMIT ISSUANCE
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OK7 Ihemby affirm that am licensed underpmvf.siomof Chapter9fcommencing with JO DGSCRII'1'ION
HW00 Seen.. 00)of Division 3 of the Boamen, it Professions Code,and my license is in PANELS T��
C U F full force and effect. UP l'02(p AMPS
FGZm License Class LiC.n
In¢a Data Contmmor 201-1 P
Fyz ARCHITECTS DECLARATION SQ.17.FLOOR AREA b/SQ.Ff.
1 undusland my plans shall be used as public me hi. OVEiR 11
ZO OZ�O .. 1
Fytyl SIGNS Ii 'IR f�irl� /JTm]
Liccmcd Nutritional7{�
y�
W< OWNER-BUILDER DECLARATION SPECIAL ' C 1.
.°KOaU I bereby affirm IItat 1 am exempt from the Comracmrs License Law for the
ue3avf—i following reasna(Seclioa]031.5,Business and Professions Code:Any city or county TEMP.ME LE INST.
F O which inquires a permit m construct.aher.improve,demolish,or repair any strucup,
to its issuance.also re ulrcs the applicant for such Permit file a signedstatement POWER DF;VICES
prior t PP pcmtf
.,<o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
1%oLL. 9(commencing wiN Section]IXYJ)ofD vistnn 3ofthe Business and Precision,Code) __16 .30tttitt"
VALUATIOCC.
��y orphot heisexempt 0erclmm anti the basin for theullegcdexemption.Any,olution of (J ��
F.7_a Secpion]03 LS by any upplicum fora permit suhjcas the applicant ton civil penalty Of UT'LITS-SWITCHES-PI%'1'I)RIiS 7V1
E
not more than un
five hundred dollars($500).D NEW RISIDfiNT1AL ELF.CIR SQ.FT. STORMS TYI'Ii CONSTRUCTION
Wm ❑ Lasowncrofthepropcny,nrmyemployceswith wugcsulheirsolecompcnxaion,
W
, will du the work.and the structure Hand intenderforoffend forsale(Sce.7044.Business
and Pmm,sfuns Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work hinuelfor through his
employees,provided that such improvements arc not atendedcrofemd mrsale.If. OCC GROUP Ras.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner-
builder will have We burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE
❑ I,as ownemfthe pmpeny,an endusivclyamtraming with licensed conlrunors to hLUOD%ONG ANN
construct the project(Sec.7140,Business and Ptofasions Code:)The Contractor's
License lzwdcesnot applymanownerafpropcny whobuildsorimprovesthcreon,end PERMITISSUANCE
whociami is forsuch pmjmtx with acommetons)licensed pursuant mtbe Comment's
License Law. ALTER-DRAIN&V FM-WATER HEA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this mason BACK PLOW PROTECT.DEVICE OUTSIDE.FEIIS
SANITARY Y N
Owner Date RECEIPTa
• DRAINS-FLUOR,ROOF.ARBA,GOND.
WORKMAN COMPENSA'T'ION IlEC1,ARATIOry SCII001.'I'AX YN
❑ I hereby affirm shall have a certificate of consent In self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT
Woden'Compemation Insurance ora certified copy therenf(Sec.3800,Lab CJ which PARK PER Y N
covcm all emplo ee's under this L RECEIPT a
Y Pc^ni GAS-IiA.SYSTEM-1 INC.O Ol1TLLTS
Policy a IS BUILDING DIVI ION IT
any GAS.FA.SYSTEM-OVER 4(EA) PIANCHECK FEE
'enified copy is hereby fumishW.
Certified copy is filed with the city inspection division. GRIASBill NDUSTRL WASTE,IMTRCEPTOR GRADING it
CERT'IFICAT'E OF EXEMPTION FROM WORKERS' GREASE'I'RAP SOILS FEE
COMPENSATION INSURANCE
(Tho,aclumnecd not hemmpletedifthcpcmal is 17oronehundrWdo11ars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE.
m les.)
I certify that in the Performance ofthe work for which this permit is issued.)shall WATER HEATER WNF- /ELC R
not employ any person in any manner so as to become subject to the Worketa' PAID
Compenstion Lawsof Califumia, Dam WATER SYSTEM/IREATING Dae Be ipta
Z Applicant
Z NOTICE TO APPI.ICANI`.If.afar making this Cenifiwm of F,xemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
[6 become suhjccuo the Worker's Compensation pro,isiom of the Labor Code,you must --
10
� ' fnnbwith comply with such provision or his shall be dcemW revoked. BUILDING FEE0. Q CONSTRUCTION LEiNDING AGENCYSEISMIC FEE
I hereby offimt that them is a construction lending agency for the performance of
Z TOTAL: ELECTRIC ITE
U 0 thnder's far which this pcmtit is (gee.309].Civ.CJ
Lender's Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEC
0 V 1 certify that 1 have real this application and spite that the above information is MECHANICALTEE
W correct, [agree tocomply with all city and county ardinancesand satehr srelming to PERMfI'ISSUANCE
F-' CL IF dingconompliunlmd herebyamhmix rcpre,cnmtives ufths city manner upon the CONSTRUCTION TAX
L) LO uMwe-mentioned properly for inspection purpmes. ALTER OR ADD TO MECII.
Z (We)agree to save,indemnify and keep loathes the City of Cupertino against
Iiuhilities.jidgmenu,inels andeapenses which may in any w,ticenactigainst said City AIR HANDLING UNIT IT 014000 CFM)
co xgax a,of the gaming adds pemtit.
AIR HANDLING UNIT(OVER 10,000,CFM)
gnaure of ApplicanVCmumcm, Dam EXI MUST I IOOD DODUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO 100,000 BIG) Duro Recelpl a
Will the applicant or future building Occupant store or handle hazadous material HEATINGUNIT(OVER 100,00JBTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)¢ VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) I$$UA�`Ifa�'.I�(s'I'E
Will the applicant or future building occupant use equipment ordevitts which emit
• hmallo t,air contaminants m defined by the Buy Amu Air Quality Management BOILER-COMP(OVER IM."BTU)
District, 13 yes - 9 1992
Yes ❑No NEW RESIDENTIAL MF.CII. SQ.Ff. 7
1 have read the has ndous materials mi,mo mems under Chapter 695 of be
TTY <,1F LI,1f Cf11119V
California Health&Safety code,Sections 25505.25533 and 25534.I undnoarodthat
if the building does not currently have a tenant,that it is my responsibility to notify the
Dcupont of the rtr anent.which must a ma Prior to isaoance of a Cenificam of
ec�upaney , 4j �
Owner or nuTnnnciN=agent P Data ISSUED BY7
OFFICE