24590 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-HLECJ IU AI. PEREYNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. n �I C(�O
BUILDINGPHQIRCTIDEN4 J J'fIFICATION G
BUILDING Al3ORI? S: .-•?„ SANITARY NO. AMILICA'1'IONSUHNUI'1'ALDA'I7
e/� ��y�JI l k
G�Vu-`--� �" z UNITM � � 1. 1�e LOTp
O E SNAN F:: PHONE: CO A i R'SNAME: LICN4 (Mdeftty O:
` le-5 !�T 1 N/C CO11R1I,11
ARCHITECT/ENGINEER: J f LIC NO: J ADDRH - Q/ ,^ 5'
❑
rq
was CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT I'LU MHCII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRI ON
pyz therehynifrmthion3ofcenuJunssand isilesnfnsCoermemmenenseisin C�.q ' ov r
Qwz Section hereby
ydf Division amlicesednmde and Mmrmarlonn Cude,)(cmmencing wa in PANELS
full
Dider ice xoA� i�ab ,f�� UP 70288 AMPS / f T
6'ZZ License las Lic.p 1/l.. 1 I
ti Qy Dam Commdor KC/ 201-1008 AMPS / e
ZOyZ ARCHI*ECPS DECLARATION OVER 1(x10 AMPS SQ.FT.FLOOR AREA $/SQ.7.
O Z-,Q I undersand my plans shall ke used as public records. n A /T g Ifs lr.� e
(a=^+� SIGNS ELECTRICAL N A L I'E �D II
g94 Licensed Professional
ga OWNER-e,ampl1?It DECLARATION SPECIAL CIRCUH'/MIS0. (\ n
cax�S OEI— 1 hereby affirm Wm 1 am exempt from the Commcmrs License Low for the ��}u L
00'30 Vs following rcuson.(Section]031.5,Business and Professions Cole:Any city or county THMP.METER OR POLE INST.
�ka)OM prior
ri rM1 requires n issuance,also
l.it o re chest sapper,imp for such
mmsM1,are a signed
statement TE'��a
Ke5af thatheslcensedpursuant
tothe
theaisions applicanttfthe Co permiuo Licese La statement POWER DEVICES G
�' pC thatntisrian,wpursuantmtheprovisionsof the Contractor's License L, (Chapter
a �4 9(commencing with Section]00()of Divisimn3of Ore l3uxineas and Pndessions Code) SWIMMING POOL ELECTRIC VALIIAIION
W_H in that herscscmpfthcrcfromandfle basis forthanlingmA exemption.Amyviolntionnl GU'I'LE'1'S-SWITCHI?5.19%TURES
Seetitur 7031.5 by any applicant a pemrit subjects the applicant to a civil penalty of �
not more than five hundred dollars($500).
m ❑ I,ssnwnemOM1eproperry.ormyemployeeswith wugesasrheirsolecmmpcnzmion, NIiW RESIDENTIAL FLELTR _SQ.FT. S'fOHiFS TYPE CONS(RUCTION
s3� will do the work,and the smuatre is not intended or offered for sale(Sec.J044,Business
and Professions Curie:The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon,and who does such work himselfom1md,1 his OCC.GROUP RLS.UNI'I'S
own employees,provided that such inrprovememaare not intended oroffered for aIle.If,
however,the building orimpmvemem is sold within one year al completion,Iheowner TOTAL:
builder will have the burden of proving that he did not build or improve for purpnae of
sale.).
El 1, mn
I,asonerofthe property,aexclusively cometingwith licensxdmntmerom m QTY. PLUMBING PERMIT FEF. FLOOD ZONE APN
onsnuct he project(Sec.7094.Business and Professions CNet)The Cmntmctor's PERMIT ISSUANCE
License Lawdoesnot apply m on ownendpnrpertywho builds or improves thercom a.d
whmeontreas l'or such projects with o rontraetor(s)licensed formula to the Cmmntemn, ALTER PA
License Law. (- ) PEESUMMARY
❑ I am exnnpt under Sec. ,B&P C for this reason BACK ROW PROTECT'.DEVICE SANITARY �Y Dl1 N
Owner Dam RECHIPI'p
DRAINS-FLOOR.ROOP,ARG,COND.
WORKMAN COMPENSATION DFCLARATION SCHOOL TAX Y N
T hereby affirm that lhave ucenifcam of consent mselGinsure,ora cenificum of PIKEORES-PER TRAP RECEIPI'Y
kcrs'C/nynrpensmion lnsmmnce orucenilied copy thereof lSee.38W,Lah CJ which PARK FEE Y_N
amov'slil/PolicykIJ � )Ihieylrtyit. DIVISIOM
-Y L GAS.EA.SYSTEM- INC.4 OUTLETS BUILDING EC DIVISION FEES
Company GAS-V.A.SYSTEM OVER 4(EA) PLANCI IECK ME
[I Cenified copy is hereby fumixhed.
t Certified copy is filN withthe city rnapemion division. GREASFJINDUSTRL WASTE INTERCF.P1'OR GRADING IEE
CER'1']FICA FE OFRXEMPION FROM WORKERS' GREASETRAP SOILS FET?
COMPHNSATION INSURANCE
(This section need not be completed tribe permit is forone hundred dellues($100) SHWER-SANITARY-STORM EA.20017, ENERGY FET?
mrless.)
I certify that in the performance of the work for which this Permit is issued.I shall WATER HEATER W/VENT/ELECTR71
not employ any perdu.in any manner so es to become subject to the Workeri 0 PAID
Z Compensation Wwsof Califontia. Data WATT?R SYSTEMtGlrAING Doc Receiptp
O O Applicant
NOTICE TO APPLICANT If,alter ranking this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. 'I'O'I'AL:
Com) become subject to the Worker's Compensation provisions of the[,shot Code,you must
Ki > forthwith comply with such provisions,this Fermi t shall be deemed meal BUILDING FEE
S Q
CONSTRUCTION LENDWG AGENCY SEISMIC FEE
I hereby affirmthat constructionm
hem is a construction lending agency for the peHorvnce of
U O rhe weak for which this .it is i...el(Sec.3097,Civ.C.) TOTAL: F.LF.CfRIC TLE
p.t Lender's Name
0
Lenders Address QTY-. MP.CI]AN[CA L PERMIT _ FEEPLUMBING FEE,
V 1 certify that 1 have read this application and nate that the above information is
cmrtect.!agree m¢amply with all city end county oNinencw and nam laws rdming to PERMIT ISSUANCE MECHANICAL FEE
_ building construction,and hereby uutharizereprtsntatives of Nis city to enter upon the CGNSTRUCHONTAX
V 2 abovementioned pcapeny mrm,pearon puryove, AMER OR ADO TO MECH.
(We)agree to save,indemnify and keep harmleas the City of Cupertino against
liabilif judgments,costs and expenses which may in anyway seems against said City AIR HANDLING UNIT(TO 10.000 CFM)
ind e I encnl the mming mf ri'pc
h 41 AIR HANDLING UNIT(OVER 10.00)CFM)
unto(Applicant/ tmmr Dam MIAUST FOOD PxODUCT)
PAID
II ARDOUS MATERIALS DISCLOSURE HUNTING UNIT fro I00,0011 BTU) Dam Receipt N
W ill the applicant or furore building,cupent store or handle haz,doua material �x
as defined by the Caperton Mmdeip:d Care,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Semlon 25532(a)R -
11 Yes 11 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCIi DATE
W iii the applicant mrfuwm building ncapant use eyuipmem or devices which emit '
. hazardous air asntuminenrs as dcfnmd by the Bay Area Air Quality Management BOILER-COMP(OVER BLOW BTU) pp Q
Dinfict] Pv
❑Yes ❑No NEW RESIDENTIAL MECI1. SQ.FT.
I have read the bcoundm s materials relmom ems under Chapter 6.9.5 o1the PAI 2 6 1993
Culifamis Deuhh&Safety Care,Sections 25505,25533 and 25534.1 undersand that IV
if rhe building dura not cuven0y have a ma.L Ihm it is my resprodhility m notify rhe
occupant of the rcyuimmuems which must be met prior ro issuance of a CeniOcme of r 1 INV
Occupancy. rt1Y car
Owner nr amhori rd agent Dote 'TOTAL: ISSUED BY:
OFFICE