24841 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES^USE BALL POINT PEN ONLY
II IL) G- 'LEC I'.CAL PERMIT NO.
CITY OF CUPERTINO PLUMBING-MECHANICAL 24841
BUILDING DIVISION APPLICATION/PERMIT
-..BUILDWG PROJECT IDENTIFICATION �. 1.+t
BUILDING ADDRESS: `f''1•s'� y, /�y�.{,(r,s(,�s//�J f� SANITARY NO. APPLICATIONSUBMDTAL DATE
'•a/+ /�/�S w�J �rl. UNRa LOT#
''TOWN�S�'AMF: i is is /PHJJNE:� CONTRACTOR'S NAME LIC NO.
�atlrfLYf-rV y.J '.IO'/VJ �IFI'�iVl NIC CONTROL#
CHITECT/ENGINEER: LIC NO, ADDR S:
7� S�
NTACT: PHONE e' '.k f ' - z err(� d ,PEE; ''+ BUILDING PERMIT INFO
/./�,,aAIa.�'
/1 /,✓ �q ^ '��'�'a1! �v�/ •'W� PERMIT ISSUANCE �� ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I`lCC_• �JOB IirDESCRIPTION
Thereby affirm Nat I am licensed underpmvisionnofCmgcr9(commencing with
sion and of DlvisionJ of the Business and Profesmiom Code,and my license isle pgNELS /1__�„ ���`
I'''
fall f Clow Dat. r6v)rq � , N-b
:yJ Lice,hse Clus Lic.# UP T020 AMPS
'a Dna Connector 201-IOW AMPS SQ.FT.FLOOR AREA SBQ.FT.
'Z ARCHITECTS DECLARATION OVER IOW AMPS
1 understand my plans sial be used ss public records.
—tail SIGNS ELECTRICAL
—, Licensed Professional
xQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
U I hemby affirm Nn 1 an exempt from she Contractors License law for she
�Qfollowing mason.(Section 7031.5,Busumss and Professions Cade:Any city or county TEMP.METER OR POLEINST.
J which mquisa as Permit to.canoes.alta,improve,demolish.or repair any snuctum
—� point.its isassnce.dso requires the applicant for such permit to fl...ignednaement POWER DEVICES
C) Out he is licensed pursuanno the provisions of the Contractors License law(Chapter
y
0 9(commencmg with Saxon 9000)o(Division3af the Busmcuand PrafeaiansCock) SWIMMING POOL ELECTRIC VALUATION
Jus or dust he is exempt therefrom and she basis for use alleged exemption.Any violence of Sw
tan �`•
:Q Sec ]031.5 by any applicant a pamitsubjeas she apcm
piina a civil pcnslry of OUTLETS-SWITCHES-FIXI'URFS
not me Nan five hundred dollars(S5W). NEWRESIDENTIALELEM _SQ.F7. STORIES TYPE CONSTRUCTION
_pro do,wnc,sould ionacty,mm.time.diximthwegesatheirce.7W.Business
3 1do,hewanx Crime:
he Contisctorimm�ense Law miffered
r sal apply 7040.ownir of
e Pmremmiam code:Tee Contractor License Law aam eat apply ro m awns err
properrywM1obuilds or improves thereon.and who does such work M1imulforthrough his OCC.GROUP RES.UNITS
own employee,,provided shat such improvcmenu art not intmded or offered for tale.If.
however,the building or improvemem is sold within oneyearofcompletm.rhe owner- T A
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ .jf"tS§ PLUMBE1G P�ERhf ZONE APN
I.uownerofthemny, mexclvivelyon=fngwiicroemnasms QY
F ,
construct Ne preject(Ser.71144,Business and Profusions Code:)The Cm,raaor's
License Lewdoesnonpplyto anownerofieropeny who bulldsmimprovestherarmand PERMIT ISSUANCE
whomntracu fmsuch projau with acontracmr(s)licensed purauenUo the Contractors ALM-GRAIN&VENT-WATER(EA)
umoselaw.
❑ 1 sum exempt under Sec. ,B&P C for this reason OUTSIDE
BACK FLOW PROTECT.DEVICE SANITARY Y
Owner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR,ROOF,AREA,COND. SCHOOL TAX YN
Iberebya thatlhaveacenifmcateofcommntmml(-insum,oraursificateof FIXTURES-PER TRAPRECEIPT#
mkeri Cmnpummon lrubsom or a certified copy themof(Sce.380,Lab C.)whichIce PARK FEE Y -
N-covers all employer's under this fiction. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy a BUILDING DIVISION FEES
Company GAS-EA.SYS (PAI/\ --� n NC'HECK FEE
[3Certified cape is hereby furnished.
❑ Canified copy is filed with the city inspection division. GREASFJINDUS ASIE INTERCEPTOR J &AGING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP L'_ IP
ILS FEE
COMPENSATION INSURANCE -
This secrimnadnot becompleted Bona Permit isfuture hundred dollars(SIM) SEWER-SANITARY-STORM EA.200 ENER FEE
or less.)
I cenify tin in the performance of the work for which this pe.I,is issued,i shall WATER HEATERW
not employ any person in any manner so a in become subject ,o the Workers
Compoma[ion Laws of California. Dem WATER SYSTEM/IREATWG Dau Raaipt#
Z Applicata
NOTICE TO APPLICANT:If,after making Nis Cenificne of Exemption.youahould NEW RESIDENTIAL PLMB. SQ.FT. TOT
become Object o the Warkas Compensation provisions of the Labor Code,you mum BUILDING FEE r�
forthwith comply with much provisions.,his permit shall be,tamed evoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm Out here is a construction lending agcnn for the)xrfon,unce of
Ne work for which this _ ELECTRIC FEE
permit is issued(Ser.307,Civ.C.1
_ Lenders Name HA u ' �. FEE 3}' PLUMBIN
Lenders Address QTY 7�_�nr MECHANICAL PERMI'TT;" 'FEE y'�
1 certify that l have read this application end sure Na,the above information is -' a MECHA FEE
correct.l agree in empty with ell city and county ordinances and state laws relating to PERMITISSUANCE
building construction.and harebyauthoria reprurnm,ives of,hisolty to enter upon he CONS UCTI NT
Z above-mentioned property for inspection pts sALTER OR ADO TO MECH.
(wet agree ave,indemnify and ep less the City Cupertino eFeinn
iflia,jud ca .cmuande.pens hie y in any way acrueagnnst mail City AIR HANDLING UNIT(TO IRO0 CFM)
in
cque a ofOgranting of thi pe 't.
AIR HANDLING UNIT(OVER 10.00 CFM)
eofA icanVContrairm am q DEXHAUST HOOD PAID
Receipt a
HAZARDOUS MATERIALS DISCLOSU HEATING UNIT(TO 10.00 BTU) Dare
Willthe applicant or future building coepee,atom or hendlehmard...me rial HEATING UNIT(OVER M."BTU)
a defined by Ne Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cods.Section 255320)' VENTILATION FAN(SINGLE RESID) Is
❑Yes ❑Na
9 BOILER-COMP QHP OR 10,00 BTU) I!" pp DATE
Will the applicanmrfntoebuildingmcupmt useequiprnmordevices whichema F
:, aur air con,aminmu as defined by the Bay Amo Air Quality Management BOILER-COMP(OVER 10,0(10 BTU)
strict? APD
❑Yes 13 No NEW RESIDENTIAL MECH. SQ.Ff. fhb 1 ZJ 4ty��
I have read the hazardous materiels rcquincomm s under Chapter 6.95 of the C!I Y JI, s /y
California Health&Safety Cade,Securns 25505,25533 and 25534.1 undersand the
if the building does no,currently have abrust,that it is my responsibility to minify the
acupant of the requirements which must be met prim to issuance of a Certificate of
Occupancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE