24493 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOI.DI C- .L. TRICA. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 24493
BUILDING DIVISION 0MILDINf:PROJECT IDENTIFICATION
BUILDING ADDRESS: n SANITARY NO. APPLICATION SUBMITTAL DATE
hn 2-9'qv I1NIT# LOT# I/ 16—7
OWNERS NAME: PHONE: CO ACT E: LIC NO:
• 3- NC CONTROL#
ARCHITECT/ENGINEER: LIC NO: DDRES :
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMITPLUM INFO
BLDO ELECT PLUMB MEH
PERMIT ISSUANCE TK3�7
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ma4z I hereby affirm that l an licensed under provisiomol'Chapter9(commencing with _
µA00 Smith.70(l Division 3ofda,Businimi.md Profcsslom Cods.and my license is in PANELS �(��
Fdo' full force and effect, l`
Rte Llama Cle LiaN UP T020T AMPS
m=y Date I Cmntmtlm 201-1000 AMPS g FT.FLOOR AREA S/SQ.IT.
,ZQNZ, ARCHITECTS DE CI. TI OVER IOf10 AMPS Q'
p 1 understand my plans shall be,used as public accords.
SIGNS
ICAL
gg ,�')j Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUI'DMISG
1 hereby affirm that 1 um exempt from the Conmacro License Lew for my P. �\J] ��
rat following reason.(Section 7031.3,Business and Professions Coo de:Any city or count TEMMETL'R OR POLE INST. II II
104r which rcya permit to canstrvet,alter,improve,demolish,or repair my structurerte'
K$'��� priortoimiss...m,alsaacquires the applicant for such Permit file..ignedatammem POWER DEVICES n
y1 C G 0 that he is licensed moment to the provisions of the Contractors License law(Chapter +�
d4o 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
ly�y or that he is exempt herefmm and he two.hrthe allegedioami ion.Any vinhtionof
�ZQan
Section]o3lS by y applicant far.permit subjects the applwanuoacivil ponahy or OUTLETS-SWITCHES-FI%TURES D D
S not more than five hundred dollars(ISM)
.
e' Po ElI.mowneroflhepropeny,ormyemployeeswithwagesmtheirsoleempmatioa, NEW RESIDENTIAL CLEM _SQ.Ff. TORIF3 TYPECONSTRUCDON
a will dothe work,andthe structure is not intended oroffcred foraWe(Sm.J004,Business
and Profess ns Code:The Connector.License Law does ml apply to an owner of
proper whobuildsorimproves thereon.anti whndocssuch work himselfor through his OCCGROUP RES.UNITS
ownamployms,provided Nat such improvements are not i mmmded or affrnrd tar sale.If,
however,the buildingorimprovement is sold within oneyearof completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las mwnendthe prmpeny,umexdmivdycanmacting wiNlicensee conoucmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
omwn No project(Sec.7044,Business it Professions Cade:)The Contractor's
License Law doesnot applyto anowmaofproperty who builds arimprovestheacan,and PERMIT ISSUANCE t
whocomracts for such projems with aro muctor(s)licensed pursuant to the Contracture
Lies.Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um exempt under Sec. ,B&P C for this moron OUISIDEFE-ES
BACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner DateRECEIPT#
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ ers'Co peirationI that haveneori morette conxnuoof(Secure,or Lab C.)ale ofwhich FIXTURES-PER TRAP RECF.IPI'N
Workers'Cumpensntion lnsumnceorucenifed copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT is
P.I.,,N BUILDING DIVISION ERS
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK EE
❑ Cenified copy is hereby furnished.
❑ Cenified copy is fled with Ne city inspection division. GREASE/INDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
O'biesection need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY HE
or lest)
I cenify that in the parts nen of the work for which this p,/eyrmit ais,inubued,l shall WATER HEATER W/VENT/ELECTR
not employ any person m s 1 two / uNB C Workers' PAID
z Gtmpensatinn Laws ofC 'mine WATER SYSTEWTREATING Do. Receipt#
Appli a t
O NOTICE TO Luftermakin a d9nifieste of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
p VJ become subject In the Work[r's Compcmelion pmrskimm of the labor Cade,you must
fnrlhwith remply with such provisions or this Denten shall be deemed revoked. BUILDING FEE Q
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 z
I herchy affirm thatthe.is a construction lending agency for the per ammnce of
U O the work fm which this Jarmil is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
u' Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
ILI I cenify that I have toad this applimom, it situation the above information is MECHANICAL FEE
P. __ren.I—g ..comply with all city and count ordinances and state laws relating to PERMIT ISSUANCE
y buddnngconxwction,an hembyauth 're scntatives of this city to enter upon the CONSTRUCTION TAX
U z above-mentioned pm for insp on 'a ALTER OR ADD TO MECH.
(We)agree m e d y kne ess No City of Caperton against
liabililics,judSm w ch yi y ay accreagaimtsu'ld Cil, AIR HANDLING UNIT(TO 10,000 CFM)
in comcquemc gm g x is 11-16
AIR HANDLING UNIT(OVER 10.000 CFM)
Sig atu¢ml ApplicenVCammaar Data EXHAUST HOOD(W/DUCID PAID
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UNIT(TO IOLOW BTU) Date Receipt#
Will the applicant or future building occupant store or handle hicardous material
m deOnW by the Cupertino Municipal Cotle,Chap¢r 9.12,and the Ileahh end Safety HEATING UNIT(OVER 100.000 BN) TOTAL:
Code.Section 25532bd?
C1 Ycs CI No VENTILATION FAN(SINGLE RFSID)
BOILER-COMP(3111?OR I W,t1110 BTU) ISSUANCE tDATE
Will,b appliamtorfummbuildingmeupant useequipmemordevices whichemit P A ' Y
. hurardous mr comaminnnts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 101,0011 BTU)
Disoia]
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.PT.
NOV 16 1992
I have read the Safety
Code
materiels requirements under Chapter erm d the -
CWifomio building
do&Safety Code,ically have.
Sectiohe 25503,253]3 and responsibility
1 understand rhes /� r•Ul-,[1'11 II'1t/
occupanftha tof gdocanutcurrswhihmust b m et it i is myyreuance bililymnodfy the VIIY Of V
occupant of the requirements which mull h mel prior to issuance ora Cenificnm of
Occupancy. ,
Owncrmialthonsed.,cut Date - TOTAL: ISSUED BY:
OFFICE.