24872 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOU N - • :C'IACAL PERMIT N024872
.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L 4 yV( L
^rBUI DING PROJECT IDENTI CATION` "�•- '
B ING ADDRESS: /��� /�N�1" SANITARYNO. APPLICATION SUBMITTAL DATE
9(P AEIvT ! UNIT# LOT '7jrl fl/i/ S
OWNERS NAME: PH CONTRACTOR'S NAhdh LIC NO:
y 4/0) C / /f6�� �i yC N/ CONTROLM
-`\— RCIIITECDENGINEE.R: LIC NO: ADORE
V�I�M+I A� Ow eg.-/MGA ❑
CONTACT: PHONE: QI'Y. T _ELECIRR IC PERMITy' r "'` .i#"xFgEje- x .:k '�.' '>� BUILDING PBRMIT INFO
��jj ��1�(r� 4W s rr j' B E PLUMB ME:CII
000-saEipirx, /l V/4Fi� T{.yJ y� 5jyIII, PERMIT ISSUANCE I KC
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, LOB UESCRIIH'ION
OKZ IhereM1yaffirm thus licensedunde,proviaioneo'Chapter 9(commencing wish
PJ0t0qqt'' fullSection
ceand or Dlciaionluf the Business/pProQfes`ions Code,and my license is in PANELS
FZuf Liernm ClassefrecLQ Lie.. 61544L UP TO NO AMPS
NF-<ew Data 11D� Contmalnr NII-11X10 AMPS
O`7Z RCll he umg DECLARATION �S{7.Fr.[I,VOR AREA 5/SQ.IT.
Z OVER IfX10 AMPS (\''YU'
ozDggq IundealAnd my plena shall be umA as public records d
FHS SIGNS ELECTRICAL
<, � LicemeJ t4ofasionnl
Lp, but I am mount fears
s the Contractors
SPECIAL CIRCUIT/MISC.
sxX OaU I hereby reason,.1flurn(Se thm I an<aempr from the C9sims Co License Lew for the
W'3LLy¢ follow%hiching Nuiraramaii to ConLmr,aBusiness,iAnd
ve.demolish,
Code:Any city structure
'TEMP.METER OR POLE INST.
BOJ wintto quiresme,also neons thepplicampmvuch Permit
ore a sig any swment
0< thim oilaiaensed lamunti the theeppllcanof the Conhamius Licese Law ta¢ment POWER DEVICES
� 9(c he islicensedwith Schon 7")of
Division
the CeBusiess License Lawns Co ref
�•�G4p 9kommisexemithomfon7000)oand e Division Sof theBusinessexesand.Any violation
Cade) SWIMMING POOL ELECTRIC III��� VALU/A�T ION
lffl onhmn7i31.5bylMrtrmm�tfarabmiafor tsubjthe tsthedesempdtoa civil Penalty
UTLETS-SWITCHES-FIXTURES ` �J ��
G
not
om man re
eeu applicaall nt S50 rah subjects the appll<mnoacivil prnelry of ` `e
O 3 l.asaan Tnfthed ny..ormyomp. NEW RESIDENT IAL ELECf0. —SQ.FT.
o n❑ oth work...dthe lgentme is not
t atenyeeawimwegesannei(Sm. N4.B ureasSTORIES TYPE CONSTRUCTION
.a will dotheand the he Conti clan's is a se Law
s not a(Sec.7044,Business
and Professions wh to Code:The Contrecmr's License Law Ante week
apply m en owner of
pmpenywhnb,pervi impmvesth impmandwtsam nor amended
hire.aelfcar eredbrouglt his OCC.GROUP RES.UNI IS
employecx,provided that such improvememaam rat ImmnAcd orof/ered Tarsale.IL
hawev l,me building m impnmemenl is sold within one year of completion the owner. —74V M
builder will have the bunlen or proving that he did not build or Imprnve for purpose of
sale.).
❑ I,as ownerorme property,emexclusively contracting with licensed canvednn to My. ,??LUMBINO PBRMIT:�3'l�.`,4i At gp88, :. FLOOD ZONE APN
construct the pmikel(Sec.7044,Business and Professions Code:)The Contractors
License Lew does not apply manownerorpropeny whobuildsor improves thereon,and PERMITISS ANC
who contracts for such projects with acontradar(M licensed pursuant an the CamaCtOeS ALTER-D0.AINA EN - A RED) _ FEE SUMMARY
License Law. ( FE
❑ l am emarpt under Sec. .B A P C for this reason PACK FLOW PRGF.VItEu`„ .I t J L ITARY G IY FIS N
Owner Date DRAINS-FL R,ROOF,AREA,CON RECEIPT
■■ WORKMAN COMPENSATION DECLARATION SCIIODL AX Y N
y Ihercby vffirm that l have a ccniricale ofcommmno se161neure,orocertlficatenf RTRAP RECEIPT
FIXTURES-
-'� �.'aken'Cumpensatian lnsurenttorecenifieJa�caospy-kthercqof2(Sec.QSX(xl,Lob Q)which PAR Y N
ars ell employee's under this permit VV(�� 71�7�OQ GAS-EA.SYSTEM-I INC.4 OUTLETS RT:CEII'ON
Cmap X— t)k 7/ - B IAING DIVISION LEES
Company ' J GAS-EA.SYSTEM-OVER PI.ANCIIECKP
❑ Cenificrl copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASETNDUSTRL WASTE INTERCEPTOR GRADING FT.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS IEE
COMPENSATION INSURANCE
ind.1,ecflart. r!mm be completed lfthe Permit is for one handfed Mines(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY I E
or less.)
I ttnify lhm in the perrotmance ofthe work farwhtch thispennit ie issueJ,lsholl WATER HEATER W/VENl7F.LECTR
Art employ any Person in any manner so as to became subject to the Workem' PAID
Compcnnumniswanf CAlifomie. Date WATER SYSTIMf REATING Dam Receipt#
O Z Applicant
z 2 NOTICE.TO APPLICANT:If.Arm,making this Certificate of Emnaption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
!—� 0 became suhjeet m the Wmker'a Compensation provisions m me Ledn Code,you moa
ai . forthwith comply with such provisions or this permit shall M1e deemed revoked. BUILDI GFEE
Z CONSTRUCTION LENDING AGENCY SEISMIC ITE
—^� I hereby affirm that is a construction lending agency fm the performance or '
U O the work for which this Permit is issued(Sec.LA7,Civ.CJ TOTAL: FLECIRIC IIif:
IJ. b-t LAr&,F Namett" PLUMBING FEE
0 (r� Leadera Aabesa QTY. ,i '';;MBCHAMCAL PERMIT"el"' ;i- '� 't
GJ T aeviry that 1 have rc.a Ina application and state that me above mratmm'on is - - Mrs l Icnl.FEECarred.l Agree m comply with all city and county ordinances and state lows relating m PERMIT ISSUANCE
" H building conaruction,and hereby authorize reprcssme0veanfthischy to enterupnn the
L) 7, aove-mentioned property for inspection purposes. ALTER OR ADD I'O MUCH. CONST IIUCTION TAX
(We)agree to save.Indemnify and keep hamtlas the City of Cupertino against
BAN lilies,judgmems,.,is and A.,.,,.which they In any way accmeagainst said City AIR HANDLING UNIT(TO 10,ft00 CFM)
<oft aria,of this permit.
3 ,� A AIRIIANDLINGUNIT(OVER10,000CFM) allas
.91
Si Safi APp cent/Comtracmr Dem EXHAUST HOOD(WMUC1) I
PA )
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10 IMIKE BTU) Dam RecciptX
Will the applicant.future building acupad atore or handle hezmdove mamdal HEATING UNIT(OVER 100,(X111 BTU) TOTAL:
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Cale,Section 25552(o)?
❑Yea ❑No VENTILATION FAN(SINGLE RESID)
.SUANCE DATE
Wilt the m
e epplicvntarfurchuilJingoccupamumequlpmcmmdevicen which emit BOILLR-COMP(SHP OR 100,00s)BTU)
-� —1mVoss is carnamints A,defined by the Bay Ams Air Quality Management BOILER-COMP(OVER 1(0,(011 BTU)
rstric f anRAI D
\ ❑Yea ❑No NEW RESIDENTIAL MF.CH. SQ.FT.
I have Teal the hamsdous materials requirements under Chapter 6.95 of the MAR 16 199
California Health A Safety Code.Sections 25505,255]5 end 25534.1 undemand that
if the building docs not amently have a tenant,that it is my responsibility m notify the
occupant of the¢quiremenu which must k mel prim to Isuanm of a Certificate of
Occupancy. .1
Owner or amnorianl Agent Lure TG7'AL: ISSI IED BR
OFFICE