24479 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBING
HUHAMNG-h:LF,C'IR[CAI, PERMIT'NO.
APPLICATION/PFRNUT PLUM EHNG-MF:CHANI ICA 24479^ /� 7 9
BUILDING DIVISION BUILDING PRUJRCI'IURN'U14'ICAI'ION L LF ff
But Il G ADDRIiSS: y SANITARY NO. APPLICATION SUBMIT FALDATE
UNIT# LOI'#
OWN R A r:I - Y HON^ �S/J CP R� gOR:SNA — n� LIC NO: _ N/C COM'ROLx
}`NIILCf/EN'IVG/INFER: LIC NO. Aw1R1IS'sl (1
pj ^I� 24-
CONTACT: PHONE. BUILDING
QTY. ELECTRIC PERMIT FEE
PERMIT INFO
BhDG ELECT PLUMS MECII
PERMIT'ISSUANCF, 13 ❑
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
M=Z I hembyaffirm that lam licemedundcrpmviainnsnf Chapmr9(commcmingwil1b /� /+��
wOO_ Section 700911of Division 3 or the Bmeincssmal Professions Cade,and my license is in PANELS /� 7\/>L x�g •�
zad1F- full fore and t. 1 v��*jtY°� ,
FLW Licen. Class hie.# UPT0300 AMPS
vl?y Uuta Cnnl S holl DEC ED OVER
-IIIIBI AMPS SQ.FT.EA.00R AREA S/SQ.IT.
Z�NZ Y ARCHITECTS DEC LA RATIO OVER If100 AMPS
O Z^ I understand my plans shall be used as public records.
SIGNS ELECTRICAL
6 j Lieeoed Professional
6 OWNER-BUILDHR DECLARATION SPECIAL CIRCUITIMISC.
doX U 1 herhy affirm that I am exempt from the Contractor.License Law Tor the I
❑xi3ay foltowiugmawn.(Section?031.5,Businesaand Professions Code:Any city orcontY TEMP.MEIERORPOLEINST. _ `U '
��-O.¢.1 wM1ieh rcyuires r permit m connruct,utter,improve,demolisM1,nr repair any numpoe
E�}5 to its issuance.also the applicant forsacM1 permit file a signed POWER DEVICES ' II�jL
prior rosed t tothe e pp pant: fin L U
�C�p 9(cthat he is Itcmg%thSction 000)ofisiortn the3 of Contractor's License Law(Chapter,CIt SWIMMINGPOOLI:1ECTRIC
ddpCC 9(commencing whM1 Semian]lXq)of Divinian 3nfthe Buslnessund Professions Code) VALUATION
�mN or That he is exempt therefrom and the basis for the alleged exemption Any viola tion of OUTLETS-SWITCIIPS-FIXTO
FZQ Sec'tinn 7031.5 by any applicant for.permi...bjeastheapplieNuma civil penalty of -�
E20 not more than five hundred dollars LS500). NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONS TRUCE ION
wm ❑ Lasownendthepmperty,ormyemploy«.with wagesasda<irsolecampensation,
a will Jo the work,and the stnrtmrcisnm inrndedoraffered forsale(Sce.]OW,Business
and Pmfcssions Code:The Camm.emr's License law does not apply to an owner of
property who builds cr improves manors,and who docs such work himself or Ihmugh his
employces,pnrvidedthat such impnwemmproamnm,irmadcloroffeed fn..ale.If, OCC.CROUP RES.UNITS
however,the buildingor improverm nt is sold within one year of ec mpletiva the owner- TOTAL:
builder will have the burden ofMoving that he did not build or improve for puRou of
sale.). PLUMBING PERMIT' FEE FLOOD ZONE MIN
❑ T,mnwncrofthepmpny,nmexclusivelycontractingwimlicensedcon.tomto QTY.
msmuet he project(Sec.]044.Bosincxs and Anfessumv Com.)The Cmntmcmrs
License Law dmesnot apply to m ownerorpruperty who builds or improves thereon,and PERMIT ISSUANCE:
who contracts forsuch projects with ecomhzcor(s)IicenseE pmsuantto the Conn dame's
License Law. ALTER-BRAIN&VLNT-WATER(EA) FEE SUMMARY
❑ 1 ren exempt under Sec. .B&P C fur dais reasonOOI:SIDF FEES
BACK FLOW PRO]LCT.DEVICE
SANITARY Y N
Owner DatcBRAINS-PLOOR,ROOI'.AREA,COND. RECEIPTIf
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hembyafErm that l have a cenifca¢ofconnem mxelf-insure.or o cenifcate,of FIXT(1RES-PER TRAP RI7CE1P1'N
ars Compensation Insurance or acertlRed copy lhCreof(Ser.38M,Lab C.)which PARK FEE Y N
q �'�}p j'P�('��'''� GAS- .SYSTE -1INCAOIALRIiCIi1Pl'p
Io icy 11 IAMLTS: ^`rte�`e+r-� BUILDING DIVISION FEES
Company nTT GAS-EA.SYSTEM-OVER 4(EA) PLANCHUCK FEB
❑ Ccnified copy is hereby famished.
�S Cromed copy:.Tiedwilh he d......pectins division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not becomplaM Bran Permit is f«one hundreldollan(SIM) SEWER-SANITARY-STORM FA.200FT, ENERGY FEE
or le".)
I certify that in the Performance of me work for which this pmarol is issued,)shall WATER HEATER W/VEN'1'7ELECER
not employ any person in any manner m a+to become subject to the Worker: PAID
Cnmpussatimn LnwsnTCnlifnrnia. Date WATER SYSTFAUTREATINO Date Receipt
O Z Applicant
7-. C) NOTICE TO APPLICANT:ILaRcr makingthis CeniOcmeof Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
f•-' fq become subject m the Worker's Compensation provisions of the Labor Code,you most
a ; (ortwim comply with such provisions or dais permit shall be demand]revoked. BUILDING THE
d (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that is a construction lending agency far the performance of
U Z - TOTAL: ELECTRIC FEE
O the work lin which mix permit h..hasucJ(Sec.30Y],Civ.C.)
Lender's Name PLUMBING FIiE
U- F Lenders Address QTY. MECHANICAL PERMIT FEE
VI certify that I have matins application and sone Thal the show information is MECHANICAL FEE
W correct,lags mcomply wida Lill city rend caumy oNinmces and amm laws rclming to PERMIT ISSUANCE
F-' buildingconstructlon,and hereby authnrirc representatives ofthis city to entefupo.be CONSTRUCTION TAX
U Z daws-mentioned property for impvtion par vw, ALTERORADDTOMECIL
(We)agree to save,indemnify and keep modest do City of Cupertino again..
Iiahilines,judgmenu.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,0M CFM)
in a neeofthegmndn This permit. p
�1 0 �S
f AIR HANDLING UNIT(OVER 10.000 CFM)
AA 0
m oApplican Connowtor Dame EXHAUST HO0D(W/DULT) PAID
HAZARDOUS MA'I'ERIAIS DISCLOSURE HEATING UNIT(TO IIXI,(X)U B"1'U) Dam Receipts
Will the epplicunror forum building«cupant>mrc or handle hvardous mmcrial da nTAL:
xs Horsed by lM1c Cupcnino Municipal Gde,Chap¢r 9.12.rnJ dac health end Safety HEATING UNIT(OVEN 100,000 BTU)
CoSection 23532(.." VENTIIA'I'ION PAN(SINGLE RISID)
❑Yes No
ISSUANCE DATE
Will thcapplicmmrfutumbuilding«cupunl tomeyuipment ordevices which can BOILER-COMP I HP OR 100[XX)BTU) fP//��
p h:vuNous air contaminants as defined by the Bay Ara Air Quality Management BOILER-COMP(OVER MT,00 BTU) y
owDt, to Cl `A/
l Yes / No NEW RCSIDENI'IAL MECII.—SQ.1-7,
I have real the hasmdaus materials re mmarenb under Chapter 6+.95 of the 'JAN 211993
California Health&Safety Cale,Sections 25505,23533 and 25534. 1 understand Nm
if the building does nal currently have a moral,that it is my responsibility to notify the
of me mydmmema w ieh am x met pri r m issuance mr ti muerte or Gil Y Ur
On raulhoriud agent Dat TOTAL: 2: ISSUEDBY:
OFFICE