24977 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Rlm....Mi.-IRT a:cTRrCAT PERMrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n ^ �7�
INILIJIN(:DIVISION BUILDING PROJECT IDEN'I'IPICAI']OO?6795
N /� L LI I
BUILDING OADDSES
�So O M LOTH GC 9 SANITARYNO. APPLICATIONS MILI,Ty(A3L UATE
OWLINE PHONE: RACI'O ' LICENJOt ! Z {-3
YO.�'' N/C CONTROL
4RCHIlLCT/LNGINEISR: LIC NO: _ AD /1 Z
❑
CONTACT: yIONq /� ..- L" k BUILDING PERMIT INFO
2-Z�11110 QTY,Ibk. W' ', ECTRIC(PERMIT� FEE -
X 5T a BLDG ELECT PLUMB MECH
G L DF, � PERMIT ISSUANCE
LICENSED CONTRACTOR DECLARATION APPLIANCES- IDENTIAL IOB DESCRIPTION
r yZ Ihembyaffon that l nn licenseduadcr provisions of Chapmr9(comnevcing with
d,',
Seminn lOUO)af ivision 3 of the Business and Professions Code,and my license is in PANELS
m full I'o a ande cel.
jLic eC1as Li[.X UP TO W MPS
,o . me Ca
nva'a 201 1 AMPS
70yRt N A HITECTS DECLARATION O RI000 AMPS SQ,FlI FLOOR AREA E/SQ.1.1.
Oi_� 1u crsmnA yplans shall be uuJ us public rccoNs. 1I '�I rfi rat �Q
0y Fm NS ELECIRI
<, :5.,, Licensed Professional 111
,Y W6 OWNER-BUILDER DECLARATION SPECIAL C U ' IS
C
p'OaU I hereby u.(Se Lha 1 um exempt from the Contractor's e:Any Lew f the
3 a H
following reason.(Section]OJLS,Business and Professions Coda Myr T" OR E INST.
which requires a permit to construct,alter,improve,demolish,or repair o
prior to ila issuance,also requires the applicant for such Aconitia fleesigneds amen E EVICE
C a<p that he is licensed pursuant the provisions of the Contractor's License Lew(Chapter SW LNG P OL ELECTRIC dSoz� Y(commencing w'nh Section]fIOU)ufDivisionJofthe Businempfin .Any iolaCode) VA�TIOf�` .\A
W_an .,,bar he is exempt Nerefromund the basis forIDe alleged eacmption.AnY violation of --//]]
FZQ Section 7031.56yanynpplicunl fm npennit stneclslhe applicannoacivil penalty of Illt S-SWRCHES-FlXTURFS r'
not more than five M1unJred dollars($500). NEW RESIDENTIAL F1ECIlt S .FT.
C . ❑ I.asownerarthe property,ormyemployeeswith wages as theirsolecompusation, Q STORIES 'I'YPECONSHUCHON
M will do the work.and the structure is not intemadoroffetM fofsde(Sec.7W,Business
and Professions Cole The Commcmrs License Law does not apply as an owner of
property whobuildsor improves themon,and whodoes such work himm1forthroughhis
own employees,providedthat such improvements are not imendedoroffereJ fofsale.If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion.the owner. AI
builder will have the burden of proving that he did not build or improve far purpose of
S11e.)'
❑ I,asnwnerofthepmpeny.amexcluxivelyconuectingwithlicenudcontractonlo QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044.Business uad Rafessior,Code:)The Contractor's
License lawdar:an..,Iym anownermOscipeny wbobuilda or improvesdamoo,amt PIiRMI'1'ISSUANCB
who contracts for such projects with scontraclods)licensed pursaanuothe Contractor's
License Lew. ALTER-DRAIN&VENT-WATER IPA) FEE SUMMARY
❑ I nni exunpt under Sec. ,B&P C for this rtuon BACK Fl.OW PROTECT.DEVICE O SIDE FEES
SANITARY Y N
-Owner Dam DRAINS-Fl.00R,ROOF,AREA,COND. RECEIPfX
WORKMAN COMPENSATION DECLARATION SCHOOI,TAX Y N
r❑ I hereby affirm that l have a cede afcomunt to self-insum,or a certificare of FIXTURES-PER TRAP RECEIFP#
rakers Compensation Insurance ora cenified copythcond(Sac.380T0,Ltd,C.)which � PARK PEE RECGIPI'p N
coven all employ under th jycknnil. / GAS-FA.SYSTTiM-1 INC.4 OUTLETS r�
Policy X BUILDING DIVIS19N FEES
Y + e n PAS^ '' SYS 4(EA) I\ PLANCHECK FEE L
CmCO
i m copy k hereby famished.
❑Nnined copy ie filed with the city inspection division. F ' GRFA EdNDU WAS(I'EINiEJ6 OR GRADING II?I!
CERTIFICATE OF EXEMPTION FROM WORKERS' ( GREASEITRAPI V SOILS FEE
COMPENSATION INSURANCE �[ es
(This section need not be completed ifthe permit is for one hundred dollars 0100) SEWi S Y- O WET. ENERGY ITH tr�
or less.) J 1. i
1 minify that in the perfmmarre of rhe work for which Nis Permit is issued,I shall _
not employ any permit in any m as m become subject ro theWohaf PAID
Compcnsationlswsof Celifomia. Date m WA'fF:R SYSTEM/1'RCA Dare Rcce Ip
Q C) Applicant _
z NoTI'ICETO APPLICANT:Ifaftec making this Certificate o'Exemption,you should NEW RESIDENTIAL PI.MB. SQ.FL TOTAL:
H .�. becomesubjuno the Workers Conn'reatioaprovisiamaftbe labor Codayou must
UILDING IgiE
W > forthwith comply with such provisimms or this permit shall be deemed revoked. B
[f] ^ SEISMIC FEE 0
(] CO NST RUCDON LENDING AGENCY L
z
I hereby affirm that Mete is a cmtswee 3 lending agency for Ne performance of
L ELECTRIC FEE
U O the work fm which this permit is issued(See 309],Ci,CJ
Iande"Name PLUMBING FEE
Leader',Add., QTY. MECHANICAL PERMIT FEE
O V 1 certify that 1 have read this application and slam that the above information is
comeO.la,mm comply withsll cityand county ordioaa<o and slore laws relating to PERMIT ISSUANCE MECHANICALITH
huildingcunsauction,and herebyamhmixereprcscaliams ofthi,city m enterupnn Nc - CONSTRUCHONTAX
V Z aMve-mentioned properly for inspection purposes. ALTER OR ADD TO MECI I.
We)agree to save,indemnify and kap harmless tho Cay of GYPic 'na again t
liabilities,] gamin.costs andexpenua which may in any way acg¢mee ns-sid y AIR HANDLING UNH('1'0 ILLOWCFM)
once dtho tooling of lhi i {/
AIR HANDLING UNIT(OVER 10.1100 CPM)
Sigmaureof cam/Commemr Date EXHAUST I IOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 10(LON)BTU) Dae Receipt X
Willlhe up,licansorfuture building oecupantstore or handle hazardous am 6.1 T L:
ns defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Y.ENI'ILATIONNG ANSI 100.000(SINGLE
Code,Section 25532(a)] M'ILATION FAN(SINGLE RIPS
❑Yes ❑No
ISSUANCE DATE
Will theapplicam(rfutufe buildingoccapeal a.scequipmemordesees whichemit BOILER-COME UUP OR 100.11110 BTU) ��1s
hmardous aur comamivants.defined by the Bay Area Air Quality Management BOILER-COMP(OVER IM."BTU) r A
islricl]
❑Yca ❑No NEW RESIDENTIAL MEC11. SQ.FT.
1 have read the ba,ardous material,requirements under Chapter 6.95 of the JUL 19g3
California Health&Safety Code.Sectigns 25505,25533 and 25534. 1 understand that — }r
if the building does not currently have u tenant.that it is my responsibility to notify the v'�r (fir
cupant of the requirements which must be met prior to issuance of a Cer ificae of L(Jrtlll Ij
Occupancy.
Owner or out borieeJ agent Date ISSUED BY: