24461 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL DIN -ELL TRI AI. PERMIT NO.
BUILDING.DIVISION APPLICATION/PERMIT � PLUMBING-MECHANICAL ^ A
BUILDING PRWECI IDENTIFICATION [ 4 L.4
BUILDING ADDRESS: SANITARY NO, APPLICATIONN SUBMITTAL
DATE
D UNIT# LOT# 11�{J rkA
O NERS NAM& e ' PHONE: CONTRACTOR'SNAME: LIC NO: l l V
NIC CONTROL#
• ARCHITECT/ENGINEER: LICNO: ADDRESS: ❑
CONTACT: PH NE -
y Q�� QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
n a / I I BLDG ELECT LOMB SUCH
U IA d I - :Nr— PERMIT ISSUANCE El� �El��(]��J 1�[�
LICENSED CON TRACfOR'SDECIARAT[ON APPLIANCES-RF.SIDEM'IAI. �� . •_' • CREPT ON I�
GK7 Thereby off vision that I 3 of ensed ffisir ss icad ieifessions Coder and my hamog with
Floc LEESectionface.
.and of Divis on 3 of the Rosiness end Professions Code,and my license is in PANELS
F< ��+( Licamr Clas efface. t UP TO 200 AMPS
d�z ly License Clesa Lic.#
az6 h Dam Co.,.., 201-1000 AMPS
zon7aARCHITECTS DECLARATION OVER Ifg111AMPS SQ.IIT.FLOOR AREA $/SQ.FU
OZ-0 I understand on,plans shell be used es public records.
QW SIGNS ELECTRICAL
ff l Licensed Professional
mm OWNER-BUILDER DECLARA9'ION SPECIAL CIRCUIT/MISC.
ALU I hereby affirm that I nm exempt from the Commemr's License Law for the
W 3 W rofallowing reason.(Section]031 5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�.l which requires a permit to construct,.[,a,,improve,demolish,m repair any structure
m}; pflamiai issuance,also roquiros the applicant for such pertni0o file alignedstatement POWER DEVICES
ILLI 'p that he is licensed pursuantm the provisions ofthe Contractor's License Law Thapter
9(cemmencingwith Seclion7000q.fOivisioa3ofthe Businessand Pinfessions Code) SWIMMING POOL ELECTRIC VALUATION
W_m
no that he isexempt therefromand the basis far the.11egad a.,numma.Anyvimation of OUTLETS-SWITCHES-FIXTURES
6 Sectio 9031.5 by anyappliemt for a petmhsubJects thcapplicanl[n aeivil penalty of \
not more than five hundred dollars($500).
1 O ❑ I,asowneroftlm 1 NEW RESIDENTIAL ELECI'R —SQ.Ff. ` STORIES TYPE CONSTRUCTION
p propery,ormyempinded cro wed forsthefSele c0 4,Bushes, VV
will dethe wons and theses ture isContra toric License
Law
wrdoes not
apply an
Business
and ProProperty
ohiolw Cada:The Contractor License oes such not apply lf ri owner of
own enywyers,powildgm improves such improvements oeseuctende omselfor through his
howemployees,ping or improvement
issomwitinwe ne lntendedomffared furthe ow.If, OCC GROUP RES.UNITS
howear ,wille...t a orImprovementissoldwithinr[build or comm.for thcown of TOTAL:
builder will have the M1uNen of proving that he did not build or improve for purpose of
sale.). .
El 1,usownerofthe property,amischadvely contracting with licensed contractors m QTY. ,PLUMBING,-PERMIT 1pgE' FLOOD ZONE APN
construct the project(Sec 9044,Business and Professions Code:)The Comment..
License Law doesnnt apply man ownerofproperty whobuildsorimproveslherenn,and PERMIT ISSUANCE
who contracts rnreuchprojects walitecmrecmr(s)Ilecneedpurmant to the Contmaods
License Law, PA ALTER-DRAIN&VENT-WATER(- ) FBESUMMARY
❑ Iain exempt under Sec. ,B&PC for this reason r UTSIDP.FF.F.S
RACK FLOW PROTECT.DEVICE SANITARY YN
Owner Dale RECFIPT#
• c DRAINS.FLOOR,ROOF, COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAA Y N
❑
Workers'
Compensation
thati Insuraave a nce
or aceateof copyttt roself-ineure,or Lab C.)which
RECEIPT#
FIXTURES-PER TRAP
Workerd Qrmpensmion Insurance aracenified espy thereof(Sec.3g00,Lab CJ which PARK PEE YN
covers all employee's under this permit, GAS-EA.SYSTEM-I INC.4 OUTLETS �� RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEG
[I Cenlfred copy is hereby furnished
❑ Certified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectioe need not be completed File,perm¢is Gonne hundred dollars(S10(B SEWER-SANITARY-STORM P.A.2001T. ENERGY FEB
nr le4s.)
l unify that In ficperformenceef the work for which thlspermlNs lssued,Ishall WATERHEATERWNEN'I'/ELECTR
not employ may person in any meaner so as to become subject to the Workers' PAID
Compamminn Lawsnf Culifomia. Dare WATER SYSTEMUREATING Date Receipt#
OZ Applicant
Z-. NO'HCH I'D APPLICANT:It,after making this Certificate of Exemption,you should NEW RES]DENTIAL PLMB. SQ.FT. TOTAL:
Fti become subject mthe Workers Compensmion provisions of the Labor Code,you..at
� , fnnbwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that hem is a conanaction lending agency for performance of T ELECTRIC FEE
U O the work for which this Permit is issued(Sec.3097,Or.C.)
L1. PLaurie,',Name PLUMBING PGE �-
LeaderIAddress QTY. MECHANICAL PERMIT a FSE:
U 1 certify that 1 have read this application and state that the above Information is - "
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE j MECHANICAL FEE
building construction,and hereby authorize representatives of Ihis sty menteru're the CONSTRUCTION TAX
U4 above-mentioned property for inspection pumoses. � ALTER OR ADD TO MECH.
(We)agree to leve,indemnify and keep harmless the City of Criterion against
Iiabillties,Judgments.costs and expenses which may in any wayacconagalnst said City AIR HANDLING UNIT(TO 10.000 CPM)
in yuence of the grcn' gof this pe 1.
/9LS�eL',C V )I/ V7 - AIR HANDLING UNI'1'(OVER 10,00 CFM)
Signature of Applicanl/Contractin 7I Date EXE IAUST HOOD(W/DUC'19 PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING ONE r(TO100,000 BTU) Dale Receipt#
Will the the Cuantor Municipal Corbel
aeuPapter9store 2,handle hazardous ad Safe,, HEATING ONE Y(OVER 100,000 BTU) TOTAL
al
As defined by the Cupertino Municipal Cale,Chnpmr 9.12,and the Health and Safety
Code,Secti�Yos32(a)l ❑No VENTILATION FAN(SINGLE RESIDE 1 ��
\ ISSUANCE
Will thea I]canmrfuwreM1uildin ruse mrdevlceswbichemil BOILER-COMP(3HP OR 100,gH1BTIl)
pp gby then Am.Air
DATE-
'hazardous air enmaminunls ns defined by the day Area Air Quality Management
' COMP(OVER 100,1N10 BTU)
strict' BOILER-
❑Yes ❑NnNEW PAID
RP,SIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the F,,-
ALo� �n
Culifomia Heahh&Safety Code,Sections 25505,25533 and 25534. l i ndentand thm G �% 9 1992
If 11.o building does not currently have.tenant,that it is my responsibility to analytic Nov o '
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy. Cf'r J W E
Owner.,authorized agent Date T ISSUED BY
OFFICE