24909 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOtl ILDING-ELF.CI'RICAL PERMITNO,
BUILDING DIVISION APPLICATION/PERMIT 1'LUMiIING-MECHANICAL
I ^ (]O BUILDING PROJECT IDENTIFICATION 4 J
BUILDING ADDRESS: E SANITARY NO. APPLICATIONSUBMITTALDATE
Q UNIT#_ LOT#
OWNRR. NAME: PHONE``: �,2 CONT CTOR'S NAME LIC NO:Itim N/C CONTROL#
,AprIyL
—
ARCHITECf44JGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT ITiE
BLDG �[LEl PLUMB ME❑CH
PERMIT ISSUANCE El
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Onaz Iherchyaffiml that lam licemsodunderplovisionsof C'hapter9(commencing with
P1100 Scminn 71X10)of Uivisitn3 of the Business anJ Professions Code,and my license is fn PANELS
��jjW
full force end Pact.
F-ZW UCen�Lis.If UPTO200AMPS flae�`-�/A- �" 9i2
m6y Dae Ctnlructu J,�W 201-1000 AMPS
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O Z—O I undemand mY Plans dull be used rs public rtcmdv.
G'4 I=Ed SIGNS ELECTRICAL
g�f� Licensed Professional
mcQ OWI am exempt
loan,the Contractors
SPECIAL CIRCU117MISC.
OyF I hereby affirm Ihal I um<nempt film the Contractor's License law for the
W3Ww whichfollowmcutimreason,(mrit Business prove,demolish,
Code:Any city oration, TEMP.METER OR POLE INST.
which requites n permit re cnrewcL alteq improve,demolish,ri mash any ttemurt
that he iliensed , ralso u requiresthe visios filhe ch Cotmerm't rile License
ned Law
POWER DEVICIZS
W C C p 9 E m a licensed pursuant the provisions of the Contemoss and Poe law(shaper -
a 5' 9that heiaex with Section bisisi�n3ef the Business and.A.,sionr Code SWIMMING POOL Ii1.F.CfRIC
gwi ) VALUATION
y orthat 7031. by
om refromnt f the hamis fonheal,egedenemPtion. civil Penalty
of OUTLETS f!
IIC<is nation]031.5iv any fmapennit subjects the epplicannoacivil penalty of /P/ ?
� not mnrc than five hundred dollars(5500). NEW RESIDENTIAL ELECB !S Q OYY
��o ❑ 1,usnwncrofthc n Q STORIES TYPE CONSTRUCTION
33 ve prnpe y,ormyempinyecs with wages us lheirsolecnmpensatinn, p T
willdrfework,Code:
no Curtianm is Lica
eLaw does red,apply town Business �- ^^ If
and Professions Code:The Contractor's License Law dao not apply e an owner of
properly whomildsnrimproves thereon,and whodeas such work himselforthmugh his f VVV RES. NITS
own employees,provided shat such improvemen H are not i mended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner- TOTAL.
C
builder will have the burden of proving that he did not build or impmve for purpose of
❑ I,rte ownernf thepmpeny,nm exdusivdyconbactingwithlicensetl contractors( QTY. PLUMI assassasD"ON6 APN
comuunt the Pori.,(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law docs not applyto anownerofproPenywhobuildsm improvesis themo and
whoeomeels for such pn�jeces with acnnotalmo)licensed pursonntm the Comosconex ALTER (IRA)
License Law. FfiP.SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this moron BACK FLOW PROTECT.DEVICE
,y SANITARY Y
Owner Dote RF.CIi1PT#
DRAINS-F100R,ROOF,AREA,CONU.
— /
WORKMAN COME fcalc of0NDECLARATION SCHOOLTAX Y N
Workers
nembynfOrmthatlhavea m.etmi ed,opcm Ioaf(Snsum,or nab C.) hickteof RECEIPTp
Wmrters Compensation lmuratlm or cenifed copy thereof(Sm.3800,1ab C.)which 1'IXTlIRCS-P[R'TRAP PARK FEE Y
j overs all entpiny le�hGAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPTp
Policyl GG((// ��JJ i.V!/� BUILDING DIVISION FEES
Company ISO1zhe^v rdax�y
❑ Cenifed copy,,hereby famished. GAS-EA.SYSTEM-OVER 4IAHF,
) PLANCCK FEE
0-RIF"ificd copy is filed with the city inspection division. GREASE/INDUSTT RL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF IW:MPION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars 1$100) SEWER.SANITARY-STORM EA.2001T. ENERGY FIRE
m less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER I IE.A1'Fit WiVENTCLECTR
not employ tiny person in any manner
s t as to become subject to the,Workers' PAID
z Compensation Lawsof Caliromia. DateRC
WATER SYSTEM/TATING Data Receipt#
Applicant
zO NOTICE TO APPLICANT:If,after making this Certificate of PAemption,you should NEW RESIDENTIAL PLMB. SQ.FT. 'TOTAL:
Frn become subject to the Worker's Compensation Imoshoom of the Labor Code.you muss
a ? forthwith comply with such provisions ,,his pennitshall be Amami evoked. BUILDING FEE
FW5 Ca CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby uffiml thatthem is a commuction leading agency for the performance of TOTAL: F.LECIRIC FEE
[❑ O the work for whichthis permit is boued(See 3097,Civ.C.)
Lenders Name PLUMBING HE F lander',Address QTY, MECHANICAL PERMIT FEE
V I certify that 1 have end this application and some do,the above information it
Hdc mer,l agree to comply withal]city and county ordinances and stoic laws relating m PERMIT ISSUANCE MECHANICAL FEEF" ,) building construction,and hereby amhtdu eprtsentotivu ofthisciy,to enter upon the CONSTRUCTIONTAX
V Z uNor-mentioned p,.,my for inspection Purposes. ALTER OR ADD TO MECIL
(We)mgr«to save,indemnify and keep hannleea the City of Cupertino against
liubi,iticajudIanumb, mas.nd expenses wMchmay to.,way accmeagaimi and City AIR HANDLING UNIT ITO U1.010 CFM)
to consequence mom grunting of this prod"
AIR HANDLING UNIT(OVER 10,"CFM)
Signature of Applimnt/Conummr Due EXHAUST HOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."B1 U) Dae Receipt If
Will the applicant or future holding occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cele,Section 25532(a)'!
❑Yrs W^N' VENTILATION PAN(SINGLE REBID) LK
Will thea applicant orfmum building BOILER-COMP(31IP OR IW,000 BIG) ISSUANCE DATE
pp guccupumuse equipmcmordevieex whichenot
haemdms it ctnmmmem,as defned by the Bay Arca Air Quality Management
District? BOILER-COMP(OVFR 100,008 BTU)
/
❑Yes v[INJ NEW RESIDENTIAL MCCHPA
. SQ.FT. 1—
1 have read the hazardous materials equilements under shaper 6.95 of the (� �
Califomia Health&$.fell Code,Sections 25505,25533 and 25534. 1 understandP
that
if the building don not currently haven mount.but it is my rcsponsibiliry m notify the
occupant of the requirements which must be met prim to issuance of a Certificate of /sly R
OccaPaney. 6n/
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE