24498 (2) ,APPLICANT T FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - [/j1 //j1 Q
CITY OF Cu RTINO B ELDING-N,LF.CI RICA], PERMI'P NO. 2 4 T V H
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DI tSION BUILDING PROJECT HIEN1'IF'ICA'I'[ON
IIUIIAING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
5- D-- d F,r UNIT LOT lla�}SSfj/V\2
OWNPRS NAMCi L 1'HONfi: C NTRACTOR'S NAME: LIC NO:
n�h N/C CONTROL#
BLUE iCTT.NGINHFR: 1 LIC O: ADDRESS: ❑
CONTACT. --- - PHONE:: Q'I•Y ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BI,DG FLECF PLUMB MECII
PERMITISSUANCE I��I El El El CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L�}
Matz Ihcmbyalr...lolumlicensed underprovixionsof Chapter9(aommencing with JOB DESCRIPTION
BOO fall iorceand of DivisionJofilm Business and Professions Code.and mylicenu is in PANELS
UU UU full force and afteer
Lic.p UP TO 200 AMPS
6z W Liccnx Class
tFirad Dec Connector 201-IMM AMPS
ZOv3 ARCHITECTS DIiCLARATION OVER 1000 AMPS - SQ.FT.FLOOR AREA S/SQ.Ff.
O Z—Im I melvisland ery plon,,hull be uacd as publir moo dx.
SIGNS ELECTRICAL
aX ['lj Licensed l'rotesrionol
5py4'a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oy V hereby uffimm What 1 ton exempt from the Convucmrx Lice Law far the
613JC,F following reasan.(Section]OJLS,Busitkccand Probations Code:Anyci,mcminly TIiMP.METHR OR POLE INS'T.
���; width,equina a pennit to carsvuet,nher,inmprovo,demullsM1,nr repair mmy xuuctum
prior to its issuance,alsorequires the applicant for such Perm Rs file a signed statement PTE DEVICPS
that he it licemcipursuam mom peovMm—fthc Comracmrs License Loo,(CFopner
n. 0 9(commencing with Section]g0)of Division 3ofmc Bmill.svnd Professions Code) SWIMMING POOL ELECTRIC '
VALUATION
LZ� Section
7011,5 bymora&omand the hmrilsobilos Ile appempdon,Aird Penaan of OUTLBTS-SWITCHLrS-
HA5ation]I13 LS by any applicant fora permit wbjects the applicant Penalty of FI%'TURES 1 1 `O, w
W�� nm more 0hen five hundmd Jollum(55001. NEW RESIDENTIAL ELECPR 5 .PT. "(,
❑ I,asnwncrofthcproperry,armyemployeeswilh wages es lbeirsolecomp¢oration, _SQ.PF. 'I'YPh CONSTRUCTION
D, will dothewons andthe he Contractors
Liceseastit arruler,].Wk 14. am,,of
and Professions Calc:The Contreanrs License Inco does net apply m an owner of
prnpeny who Indictor brynoves themon,and whodoas such work himsNfel drought his 'A,:
employees,providW tM1nt suchimprovemenrsarenotimendcdornffertd Torsade.If. OCC,GROUP RES.UNI'T'S
however,the huildingor holoovenienl is sold within one year of completion,the owner- OPAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ Lasownetoftbe property,amerclusivelyconlmcling with licensed onhuctarm QTY, PLUMBINGPERMI9' t
,Loon u3NF APN
mstruct the project(Sec.]044,Bminet and RaPosslons Code)The Contractors /
License Lawdoesaolvpply manuwnerofpropeny wutbuthitermprovestmixim, nd PERMIT ISSUANCE
11
It,
who concocts forsnch projects with acentracens)licensed pursuant me he Connmuses AL'1'IiR-DRAIN&VIiNT-WA]lik(IiA
License Low. ) PEE SUMMARY
❑ I am exempt under Sot. ,B&P C for this reason SIDE FM IS
. . .. . _ BACK 11000 PItOTF.C'C DIiVICIi SANITARY Y N_
Owner Uta° ORAINS-Iq.00R,I200P,ARFA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N_
❑ IherebynffmtnhmlM1avenwnifiaateof cansennn sel4lnxure.ora certificate of FIXTURES-PER'IRAP RECEIPT'#
Wnrkers'Compensalian lnxuranee oracenified cnpytherwf(Sw.3g00,Luh CJ which PARK FEE Y_N
coven all emplayee'a under this permit. R17CFTPT#
Policy# GAS-IiA.SYSTLIM IINCA OUTLETS
BUILDING DIVISION IBiIiS i
Company GAS-EA.SYSTTM-OVER 4(PA) PLANCHWK IEE
Cerlllial copy is hereby furnished.
Certified copy is Bled with the city inspection division. GRF,ASPdNDUSTRL WAST Ii INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS" GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This simian elmdnal be completed tithe Perri,is intone hundred dMIms I$USE) SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
or less.)
I really that in the perfommnceofthe work for which this permit isex,eed,lshall WATER HEA]EA W/VF,NTIELECTR
nod employ any pcnon in any manner so as in become suhjcct M,the Works,, PAID
O Z Ctut'remmn Lawsof Colifnnia. Dae WATERSYS'IEMORCATING Dam Receipt If
Applomen
z 0 NOTIC1710APPLICANT If.at",making this Certifiwm of Exemption,you should NEW RESIDENOAL PI.MB. SQ.FT.
TOTAL:
[G become subject to the Worker's Compensation provisions of Ma Labor Code. no most
fonhwilh comply with such pmvisians tor his pcnnin sh:dl be dermal revoked. BUILDING FEE �s
1 (] CONSTRUCTION LI'NDING AGENCY SEISMIC FIi13
=) z I hereby affirm that there is a conwuction lending agency for the Performance of
U O the work for which this permitk issued Chm.3097,Civ,CJ TOTAL: ELECTRIC PEE
Lender',Name
U Lender:.Address QTY. MECI IANICA1.PERM IT FEE PLUMBING PEE
I lenity What I have read this application cod alae then the above iefommlion ix
acorrect.I agree to comply with all city and county ordinances and state laws mimmgm PERM IT ISSUANCE MECHANICAL PEI:
0 buildingeoustruction,and hereby authnrize mpremendivesof this city mercer upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONS'I'RUC3'IONIAN
(We)agree to save,indemnify anti keep Ennobles the City of Cupertino against
Iiabililies,judgmees,costs andexperens whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10,0011 CFM)
in consequence oftheg anti l pemmil. Q
11//I / AIR HANDLING ON]'1'(OVER HJ0M CFM)
ig l ecunVCoeecmr a Dale EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATER ALE: H
S DISCLOSUREATING UNIT(TO 100,10)BT ) Date keceipl#
Will the applicant or future building neetmart store or handle hanadous omental
m defined by he Cupertino Municipal Code Chapter 9.12,and the Heahh and Safety HEATING UNIT(OVER 100,000 BTU) 'TOTAL:
Cole,Section 25532DU
❑Yes ❑No VENEI'ILA9']ON PAN(SINGLE RISID)
WilHbevpplicanmrPowre builAingacupant usecquipmenmrdevi«swhiehemit
BOILER-COMP CUP OR 100,010 B1 U) ISSUANCE DATE
lrardoes air comamimmfs rs defined by the Buy Arca Air Quality Manigsment BOILER-COMP(OVER 100.000 BTU)
UlSlriCl]
J ❑Yea ❑No NEW RESIDENTIAL NIECE I. SQ.FI'.
1 have mild the Insertions noterlaN requommuns under Chapter 6.91 of the
'C#lifoon Heahh&Safety Calc,Sections 25505,2553)and 25574. 1understand that PAID
"Le,the building dimes not currently have n lemmt,Choc in is my responxibility m nntlfy the
cupam of the mignmments which must be met prior m issuance of a Cenibcam of
Owner,,use
'tl I
Owner nr amhnn'sed agement Date TOTAL: ISSUED BY:
OFFICE . ry S ,j -'�''