24704 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING PENMITNO. a� O
CITY OF CUPESIO NO APPLICATION/PERMIT PLUMBING-MIDENT C 'LJ
BUILDING DIVISION BUILDING PROJECT.B)F.NTIPICATION^!(.-.'-�"+�-
41
BUILDDIING�A]DDRESSS��}''� 1.Nrx s�'� SANITARY NO. APPLICATION SUBBBMITTAL DATE
1I( (JVI owwoo✓ UNIT# LOT# ^�—
_4
OWN ERSN E: l PHONE: CONTRACTpR'S NAM' �IL nQ LIC NO.
1�+ 1P 1V Nrc CONTROL.
RC I CT/ENGIN LIC NO: ADORES
Ni`A
7r I vP r
r CONT/ACT: / PHONE:
Q.I,Y y! :^ �u�:�C R "` A Ki4-E0" i-5.'',.' r;, �,BUD.DING PERMIT INFO
PERMIT ISSUANCE ~.' _ BLDG EL PLUMB CH
—
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-REST NTI ^ O DESCRIPTION
]CZ IherebY affwthmlem licensed untlerProviaionsof Chapter9(cammencingwith / I vD
900 Sectiohmbyaf DrvisioIml NesMno¢andvisimsinns Code,a(m=ccenseisin PANELS ///
;UF full force and effect. v2�� Up T02(NIA PSo
gZ Licenu Clens .Y CIL.# b
=y Date aor 1/g1Q.',S 301-1000 S 5
=y ARCH . SDECLARATION OV SQ.FT.FLOOR AREA �j S/SQ.FT.
J m ims s p 1' mcmds. V O 9 3
.Ful G CTRICAL V V
�J a sW Profess on
5d'6 OWNER-BUILDER DECLARATION IAL
5wu I hereby of na tot 1 am exempt from the Contractor's License lace for [ L)r !s �
iO o,, following won.(genion 7031.5.Business and Professions Cade:My city at many TEMP.M R MS
which sensors a pewit m ronswct alar,improve,demolish,or repair any apurcutt
3}� prior to its issuance,also am,dres the applicant formcle pewit to fl...naedsuarrom POWER DE
Y<p that he is licensed premium so the Provisions of Ne Connector a Lice.w Law(Chapter
❑ SWIMMING L CIR1C VALUATION
9(wmheeis ixemit dicrafrn70ndthe Division3of the Business and Pmfcssiotu Code) ////pyyyyy
n.Mm
or Nn he is exempt Nerefromantl the basis fmthe alleged exemption.Myviolenon of " 'l D� ttc l
=KGSarnia.7031.5 by any epplicsnt for a permit aubjecu the applicant a civil Penalty.( UTLETS-SWR ES-FIXTURES (r
of mart that five hundred dollars(SSW).
% p NEW RESIDENTLV.ELECIR _SQ. IFS PE CONSTRUCf10N
; pro n❑ hssowneroftheproperry,ormYemPloye«withwagesesNeinolecompewetion,
y3. willdothework.mdNeawctumisnotintmdadarofferedforule(Sec.]064.Business
and Profeuions Cade:The Conuncmr s License law does not apply to an owner of
pmpertywhobuildsmimproves thereon,and whodoessuch weAhimselfon)roughhis �� _GROG RES.UNITS
ownemployces,pmvided Wtauchimprovemenuaunotintendedoroffcm for We.If, IKI
however,Nebuildingarimprovement issold within one year of improve fo,pu owner-
bNMerwill have Ne burden of proving Net he did not build or improve for purpou of _
We). t
l,wow"roffficPro y,amexclusivel trutin wiNlicenredcontractorsto T�"'" 'f�'PLUMBIN6 PERhBT'E: ' `�y0 PCByr #A
Yron g Qe,M.ifn�w'''n',Yu'sv,+svwmir,x5avtiim:.4':d.:' s:4{' ,.xw.-C%�1,},
romwn she project(Sce..at.Busmen and Professions Code,The Conerecidmm,tors PERMIT ISSUANCE
i Litttuelawd«snotapplythea.ownmofproperrywhobuildsorimpmvexthereon.and
who conwctsforsuchpmjecu wlNaceneamods)licensed porsusnt to the Conbanor's
Li. Law. ALTER.DRAM&VENT-WATER(EAIFEB-SUMMARYtj<ya,F33.,d'Se„:', .
❑ 1 am exempt undo Sa. .B&P C far Nis reeronOut BACK FLOW PROTECT.DEVICE 1
SANITARY YN
Owns, Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y—N
—
WORKMAN
Natlhaveamnificmcofcortsentwulf.inaurt,oremr ficauo( -PER.j�p ' RECEIPfM
Workma Cranpenution lnsuunce me rectified ropy tortof(Sec.3800,US C.)which PARK FEE Y N
"V sallernployra'vundm Nis pe wit 1 ��#
cumGAS-EA.SYSTEM-1 INC.NC40Ifp.ETS �� BUILDING DIVISION FEES
PollcyY
Company OAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE Iq 0
❑ Ccrdfedcopyisherebyfumished.
❑ Cenifad copy is fled with the city inspection division. GREASEANRISTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed not hamen,oad ifthe parmit is forom hundred dollars(SIM) SEWER-SANITARY-STORM EA.=FT. ENERGY FEE
or less,
I certify Nu in Ne pc,f..mof the work for which this pewit is issued,l shall WATER HEATER WNENT/ELECfR
not employ ayWnfyaaperson inf�ppatn�ny�manner so to_becoye subjpft Lo the Workers'ConapeanWATER SYSTEM/IRFATING PAID Dme Rettipta
z' PPbcartt tt fir'V s/-car 1#Yla I D��—) *17.-,aa--'II JAY j3
0 NOTICE TO APPLICANT:If,after making Nis Cardfics.of Exemption, on should NEW RESIDENTIAL PLMB. SQ.Pg. TOTAL:
2 M hemommbjmt to tha Werkee,Campanian..previsions of the Labor Code,you most BUILDNG FEE aa—
> foMwitb comply with such provisions or this Pewit shell he deemed revoked.
�] CONSTRUCTION LENDING AGENCY SEISMIC FEE
] z 1 hereby all that there is a commucttan lendsng agency for do performance of ELECTRIC FEE
O the work for which this permit s tasued(Sec.3097.Csv C) �C
Under Name -`ter a 41^. u.s x^' e 4r^' cY-
v a /y _ y ,' PLUMBING FEE
� Lender s Address QTY. trx MECHANICAL:PERMIT t .s �Y�FEB.t ,i
1 mittif Nat 1 have mad this a lication and state shuttle above infowmion is -' -— ' - l!I 5 -—11' s'I' .t
y L2a Y PP I MECHANICAL FEE
rowing lagmemrm,are with all city and Count}'ordinances and smelaws relmin the PERMIT ISSUANCE
uj
building romhucnoo,mdherhoopehodureprtgenutircsof Niscity reenter upon the CONSTRUCTIONT
z above-mentioned to me., for inspection purposes. \ ALTER OR ADD TO MECH.
(We)agree to save,indemnify set keep may in a the City c Cupertino against
liebilities,judgmenu,rosuend expenses which may in any way seer again.said City AIR HANDLING UNIT(TO 10,000 CFM)
inconsequenu fthe gmnp ofthis Pe
//� /// �r rs ��Lq'. AIR HANDLING UNIT(OVER 10,000 CFM)
Si hcant/Contrictm— "+•f !J` Data (�
EXHAUST (W/DUCT) PAID /
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM.”BTU) Date R
Will the applicant or future building meopant.mein handle hamrdous metrial HEATING UNIT(OVER Iffy"BTU)
as defend by the Cupertino Municipal Code.Chapter 9.12,and the Health end Safety
Code,Section 25532(e)?, VENTILATION PAN(SINGLE RESID)
❑Yea w.
ISSUANCE D E
Willtheapplicantmfut Wildtngmcupant use equipmemordevices which emit BOILER-COMP OHPQR=,"BTU) F�
harardmts air cammu anu u defined by the Boy Area Air Quality Management BOILER-COMP(OVER IW,0W BTU) P b
District?
_ ❑Ya X. NEW RESIDENTIAL MECH. SQ.FT.
1 ave read the hvardous materials requbemenu under Chapter 6.95 of the FEB 26 1993
Califomia Health&Safety Code.Sections 25505.25533 and 25534.1 understand that !s t
if the building does not currently have.tenant Nn it is my responsibility to redly the CII l V
U k/U(-Cg h1v
occupant of lipsrquinemands which mus}j� 'm to is uance o Cenlfrate of
Occupant / m r
�11x �A {/�
Owner ca uthoriud agent K# Data 0— ISSUED BY: ` "V- •IL
OFFICE