24813 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-F.ECHA ICA PERMIT NO.
APPLICATION/PERMIT rLUMBING-MEcxpNICAI. 24813
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION `,
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
/fq4 Ua UNIT# LOT#
OWNERS NAME: - PHONE: C(]p{{ITRA R'S NAME: LIC NO: NIC CONTROL#
J. n
ARCHITECT/IiNGINIRM: LIC NO: GORE'S:
CONTACT: - PHONE:PHONE7 I " BUILDING PERMIT INFO
QTY. .ELECTRIC PEIMIT FEE
BLDG ELECT PLUMB ECH
PERMIT ISSUANCE - 'E E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mmz I hereby affrmthat l am licensed underpmvisions ofatipter9(commencing with
gi100 full fon]OOd e f Division S of the Business and Professions Code,end my license is in PANELS I
KI� full force and effect. - - UP TO 200 AMPS rT ,Vl
Qz� Limenu Close Lic.p '
w Date Con inuum 201-1000 AMPS
z Oyu ARCHITECTS DECLARATION OVER 10 0 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0 I understand my pJims,hall b,usedus public records. _
W QLicensed Professional SIGNS ELECTRICAL .
�J that
I am-B exempt
fr n the CoATION SPECIAL CIRCUIT/MISC.
Jq�O y U 1 hereby affirm that 1 am excmp[from the Contractors ro License Lew for the
s+13Wtia followinguiresa (Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. /••��
I'J ON.] which requires n permit to
m consumer,aper,improve,demolish,or repair an
y structure
Jprior tsIati rectums for such penalno file asignedsta[ement POWER DEVICES
�M0 that he Is licensed issuance,
to the Provisions oftho Contractor's License Law
(Chapter
Pip that
he is exempt therefrom
3ofNeBusiness end.Any iolaCode) SWIMMING POOL ELECTRIC UATTON
ly�y Sector h70315It yiffrI and the pc.basi .bjcctr the legedexempti to civil Penalty
of OUTLETS-SWITCHES-FIXTURES
>a
Sector
by uny applicant fora permit subjects the applicen[toacivil penalty of
A not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR —SQ.FT.
p [II.asownerofthepTo any,ormyemployeeswithwagesastheireolecompensation, STORIES TYPE CONSTRUCTION
y3°.. will do the work,and Theatrucons,isnotintendedoroffered forsile(Sec.4044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuilds orimproves thereon,and whodoes such workhimselfmthroigh his - -
ownemployees,provided that such improvementsmnotintendedorofferedforsale.If, DEC.GROUP RES.UNITS
however,the buildingnr improvement is sold withinone yearofcomplepon,the owner.
builder will have the burden of proving that he did not build or improve far purpose of TOTAL:
s IeJ.
❑ I,asowneroftheproperty,amexclusivelyconimciingwithlicensedconnatoram QTY. PLUMBING PERMIT .FEE FLOODZONE APN
commoner the project(Sec.7044,Business and Professions Cale:)The Contractors
License Lawdoesnotupply to w ownerofproperty whobuildsdrimproves thereon,und PERMIT ISSUANCE
whocommosts forsuch projects with aconannote(s)licensed pursuant to the Contractors ALTER (EA)
License Law. FEE SUMMARY
❑ I nm exempt under gee. B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE E N
Owner I Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I herebyaffnn that l have a cer[Ificate efconacnt to self-insure,or a certificate of RECEIPTN
Workere'Compensation lmumnce or a certified copy thereof(See.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
overs all employee's umdcr this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT it
Policy at BUILDING DIVISION FEES
Company - - GAS-EA.SYSTEM-OVER 4 IRA) PLANCH[CK FEE
ElCerifed copy isherebyfumished.
❑' CcniOed copy is filed with the<iry inspec[ion division. - GREASFANDUSTRLWASTEINTERCEPPOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS PER
COMPENSATION INSURANCE
(Thitowaion need not he completed ifthe permit is far one hundred do11os(SI00) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WNENT/F.I.ECTR
employ any person in uny manner so as to become subject to the Workers' PAID
Co ration ws of Cnlifamia. WATER SYSTF.MIREATING Data Receipt#
0 z 1 E i:�n. . . d �\e• 1.AA
z N CE TOAPPLICANT,If;aftermaking this Certificate of Exemption,you should NEW RESIDENTIAL PLM¢. SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
L>J CONSTRUCTION LENDING AGENCY SFISMICFEE
2 Ihereby affirm that them iae construc[ion lending agency for[he performance of -
0�••� the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
w E Lenders Name , ,
Lenders Add.. � QTY. ..., MECHANIgAG'PBRMPP `-pgp PLUMBING FEE
U 1 certify that I have read this application and state that the above Information is
>` a correct.l agree to comply with all city and county ordinances and state laws relatng 10 PERMIT ISSUANCE- �/ - MECHANICAL FEE
pj building construction,and hereby authorize representatives afthis city m enter upon the -
above-memioncd properly for inspersion purposes. ALTER OR App TO MECH. CONSTRUCTION TAX
(alp)agree an
,nue,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs andexpenses which may in anyway aecme against said City AIRHANDLING UNIT(TO 10,OOIIGFM)
s quenceafthe granting of this it. -
ca '�_ AIR HANDLING UNIT(OVER 10,000 CFM)
al 4 igna'u o pplicant/Cnalmctor -Date EXHAUST HOOD(W/DUC`G
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Date Receipt If
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(¢)?
❑Yes No
VENTILATION FAN(SINGLE R&SID)
❑
1USQ CE DATE
Will the applimlorfu[urebulldingoccupantuseequlpmentmdevices which emit BOILER-COMP(HIP OR IOO,nIXI BTU) P V'� 1
Intruders air contaminants es defined by the Bay Area Air.Quahly Management 'BOILCOMP OVER 100,000 BTU)District? ER ( .g 1993
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cale,Sections 25505,25533 and 25534. 1 understand that rr Ut Qj�I C
if the building does not currently have a tenant,That it is my responsibility m notify the C1�1
occupant of the requirements which must be met prior m issuance of o Cenificatc of
Occupancy.
Owner or authorized agent Date T ISSUED BY:
OFFICE