24818 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO LUMBING-LLEC ECC NICAL PERMIT NO.
24818
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDFN'II F'ICATION
BUILD7
6
` M�i+ SANITARY NO. APPLICATION SUB/M�ITPAL DATE
2OTp 3/f/OI
OWNERS NAME PHONES CONTR CTO R'S NAM : LICNO: N/C CO_ROLMII
SRCHITECU/ENGINEF:R: LIC NO: A SS: �� ���� ❑ ��
CONTACT: pFio BUILDING PERMIT INFO
G�I as7 /�/� ELECTRIC PERMIT FEE BLD BUILDING
PLUMB MfsCH
Cy PERMIT ISSUANCE _vv ELECT
IITUM IECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R F. JOB DESCRIPTION
qmz I hereby aRrm that l am licensrAunderpmvisions ofatipmr9(commeneing with
uJ00 Section]000)of Division 3ofthe Bneinessund Professions Code,and my license is in PANELS
IF- fur l force and sffxl.
F-ZW
License Clams Lic.p _gj()AM A
yFy De C.mmcm ' p .I p= mgRCliCRz ' A'ION
SQ.FT.FLOOR ARG $/SQ.FT.
O Z E W I uadrrsnaad my plans shill latencies public rccoNs. I AMPS
a, g/L/-xJ,11`ya/1`
4 'LECIRICAI.
6 �4 Licensed Professional
OWNER-BUILDER DECGRATTONS ECIdrCI UI M
�j O y F affirm 1 hereby othat I am exempt from the Cerement's Lir.Law for the `uJ
ts�3R-m following ouramm(Section 7031.5,Business and Poefasims Cod c:Anyciryorcounty fFMP. h ' OR ST.
�o" which requires a pemrit to conume,alter.improve.demolish...repair any swcmrr
prioeminsissuance,al so requires the applicant for such pemut m rile a signed statement POWER .VICES
y p0 Nat he is licensed pursuant to the provisions of the Comrachors License law(Chep¢.
LL�4 9(commenting with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC UA ON
W m or that he isexemptIhm
erefroandthebasisfortheallegedexemption.Anyviolationuf OIITLEfS-SWITCHES-FIXTIIRFS 8 K/
(_zaSection 7031.5 by any applicant for a remain subjects the applicanrno a civil penalty of
nm ort than five hundred dolhrs($500). NEW RESIDENTIAL ELECTR _SQ.FT.
0 asowner
orthepmmet...rmyemplrifix r thced becsme"a,,oxa.murion, STORIES TYPE STRULTION
d will do Network.andthe he C."isnot,Licaove La a does ntapply I.wo Business Q
and Property
who bu Cade:The Contrante's License law does or apply to an owner of
propertywho s,buildsorimpmvcsthereogand who d«nmchworkhimxlfor through his
ownemployeea,providalthat such impmvemen0vre notimrndaloroffered foreele.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,theowner-
builder will have the burdenor covin that he did not build or ins TOTAL"
moving improve purpose of
ale.).
❑ I,as nwncrof Nerrnpeny,am eulusivelymnnacting with licensed cnnnracprsm QTY. PLUMHING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.]044,Business and Professions Cale:)The CommunitiesPERMIT ISSUANCE. `� U 36Y-az �
License law docs not apply loan owns of property who bui Ids crimproves thereon,and
whocontrams forsuch projects with acoaupursuant actor(s)licensed pursuano the Contractors ALTER ( FEESUMMARY
License law. WATER G)
❑ I am exempt under Sec B&P C fo his SID.FEES
r BACK FLOW PROTECT.DEVICE SANITARY YN
caner Dam DRAINS-FLUOR,ROOF,AREA,COND. RECEIPTk
WOR AN COMPPNSATI��JJ11 DECLARAT19911 SCHOOLTAX Y N
❑ I hereby uffirm thmlhav<a cenifiam>1omsem pse,lf-ins6rc.An nificamaf FIXTURES PER TRAP RECEIPT#
'Workers Comprnsation Bsumnce ora certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA. M-
SYSTEI INC.4 OUTI.RTS PT-
RECEI #
Policy# BUILDWq DIyJSIONMETla
Company
❑ Certified copy is herebyGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
[IO
the
1
Certified ropy is riled
sbed.led with alterity inspection division. GREASFONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOULS
COMPENSATION INSURANCE
(this secronnced not be completed ifthe permit iv far..hundred dollars($100)
or less.) SEWER-SANITARY-STORM G.200FT. EVER I '.
'
I rectify Nal in the perfonnonce of Ne work for which this permit is issued,I shell WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject 1.the WorkerPAID
O Z Compensation Laws of Culifomia. Date WATER SYSTEMIMEATING Dam R sip
Applicant
Z NOT ICE TO APPLICANT:ILaOer making this Cenffleme of Exemption,yo..heard NEW RESIDENTIAL PLMB. SQ.PT.r. TOTAL:
fn become subject o the Workers Compensation provisions of the Labor Code,you must '$
7 forthwith comply with such Provisions m this permit halt be deemed revoked. k 0)-s l 3 6 3 BUILDING ME _kgs
[Ta (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihcrebynffirrnn
thm therciacommuction lendingagency forlheperfornmews.f /1�
LJ O the work far whish this permit is issued(Sao 3097.Civ.C.) TOTAL: F.LECIRIC FEE Q -3 . 3
D. Lenders Name PLUMBING FEE 3
O Lenders Address QTY. MECHANICAL PERMIT FEE
I.[agree
Nm 1 have read this sty loth application and stem that an above information mlation is ' Q MECHANICAL FEE b 3
�-t C correct.c enser m on,emptyand with y waffi mM count creatianere and nate laws r upon
N 'PERMIT ISSUANCE
Uto building construction,pro and hereby of Nis city noenmr upon the
V 7 uhov(We)
property inspection keepourpose, ALTER OR ADD TO MECH. CONSTRUCTION TAX
G7 (We)udg a to save,indemnify and kap myin s the City of Cupertino against
liabilinies,judgmen¢.cosu and eapcnseswhich mayin any wayaccmeagaYnsn aidCity AIR HANDLING UNIT(TO 10,000 CFM)
aas,ue e thispermit.
1I AIR HANDLING UNIT(OVER 10,0011 CFM)
fg.ImWMpB1Emnrwtop —/- m EXHAUSTHOOD(W/DUC-n
PAID
HAZARDOUS MATERIA DISCLOSURE HEATING UNIT TO if."BTU) Dam Receips,
Will the applicant or future building occupant siert or handle hareNous monist
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,010 BTU) TOTAL: 1. 1i
Code,Section 25532(a)'1
❑Yea 11 Na VENTILATION PAN(SINGLE R15ID)
ISSUANCE DATE
Will M1e applicant oil'uwrebuilJingoccupantuseequipmemordeviceswhichemil BOILER-COMP(311P OR 100,0310 BTU)
nrsmd1 us air conuminems as defined by the Be,Area Air Quality Matters... BOILER-COMP(OVER 000,000 BTU) P P9 p '
❑Yrs ElNo NEW RESIDENTIAL MECH. SQ.Pr.
1 have read the hazardous materials requirements under Chapter 6.95 of the 1 0 MAY 17 1993
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand Nat
if the building does not currently have a nrnant,that it is my responsibility p merry the
ccupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
CITY Ur vurcnwvv
Ownt-miuthodzedagemn Date TOTAL: _ 3 ISSUED BY: x
OFFICE