24517 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOLDING'ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL ^
OU�I,UING DIVISIONBUILDING PROJ4517
ECT IDENI IFICATION c
BUILDING ADDRESS SANITARYNO, APPLICA'1'ION
�SU�BMIIq'1'A�L DATE
UNIT# LOT# 1 --�J_t
_ -OWNERS NAME: PHONE: CONTRACTOR'SNAME: LIC NO: N/C CONTROL# V�
-hJ-nb ¢ c 55859 1 /
RClil';'ECI'/IiNGINP.F.R: I LIC NO: ADDRESS b
S o 25��&� Z S I to S li IIJIR� cA
corrrAcr: PIs/NE: k / QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
zzSrsDQ�IErD C°S3fy� BLDG yLI;T. k�p M 11
C' Vizi
PERMIT ISSUANCE ��'� ITrJa-A/`...
LICENSEDCONTRACfOR'SDF.CLARATION APPLIANCES-RESIUENI'IAL
I hereby ffirm that l am licensed under JOB DESCRIPTION
POO yu pro Professions
Code,
(commencing with sw_
POO Section lIX#I)of Division Jof the Business and Professions Code,and my license is in ppNF.IS
q ud z F full Tose lard effete. ��
Q U License Clue. Lick UP T0200AMPS
Cammmor SQ.FT.FLOOR AREA $/SQ.PI'.
I—rOnZ ARCfIITECTSDECI.ARA'IION 2111-IIIIXIAMPS
20m'— !understand my plans shall be used ee pathic records. OVI; IWo AMPS
OZ-W A N
P ee E W SIGNS ELECTRICAL
¢Y n j Limned I'mfewional
aOk!u that
I am-BUILDER❑ItC ContraON SPECIAL CIRCUIT/MISC. LIE
OaU 1 hereby...Se that 1 am exempt from the Contractors Co License Law for the
W a W y followinguires a (Section To3LR 9usfness send improve.
de io demolish,
Cole;Any dry or county TEMP.ME'T'ER ON POLI3INST. I� n T
which requiresneals newms the alter,improve,demolish,fie a sig any manure oV'
E R
�'W of pat heor to
scsused pursuant
to the propplicant ufmsuchpemduo filLicense
Law ubmrnt POWER DEVICES
W�pO that he is licensed pursuannothe pmvnions of the Canvacmr's License law(Chapter
d o�' 9(commencingwithSection7000)orDivision3oftheBusinessandProfessionsCode) SWIMMING POOL ELECTRIC DA
TI
Wr^ or that he is exempt therefrom and the basis for the alleged exemption.Anyviolmian of UT'LEI'S-SWI'ICIIES-FIXTURES
LYEGSection 7lpl.5 by any applicant for a pemrit subjects the applicant to a civil penalty of 4
O not mora than five hundred dollars($500). V ♦ j)
, ❑ I.asownttofthepmNp y,onnyemploymswiihwagesestheirsolecompensation, NEW RESIDENTIAL ELf:CTR —SQ.FT. STORMS '1'YPECONSTRUCTION 1
y3— wlllduthe work,andthesvucmbe isnm intended oroffcend mrsale(See.70T4,Business
and Profeasiunx CMe:The Contmenars License law does not apply m an owner of
property who builds cr improves thereon,and who dues such work himselfor through his
own employee%,provided that.such Improvements lila notintendefloroffesed fomale.If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year offlmpletion,the owner. - I L
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑
QTY. PLUMBING PERMIT ,FEE FLOOD 20 E APN
construct the project(Sec.7044,Business and Professions Cade)The Convhemr's PERMIT ISSUANCE
License Lawdres not apply to nn uwnerofpropcny who builds or improver,thereon,and
who contracts for such projects with a contractorpmdeemed puaumnmthu Con¢acmr's gC1'IiR-DRAIN&VIiN'1'-WATER V
License Law. (EA) 173E SUMMARY it
❑ 1 am eumpt ander Sec. ,H&P C for this Gascon
BACK FLOW PROTECT,DEVICE OUTSIDE b
SANITARY YN
Owner Omc DRAINS- RPCFUvr# i
WORKMAN COMPENSATION DECLARATION FLOOR.ROfIP,AREA,COND. SCHOOLTAX Y N_
❑ Thereby uffvm that llrrvenccrli Ticale of cnnsenuo selGin...r,onhccgUa huf FIXTURES-PERTRAP ^re RECEIPI'k
Workera Cumpcnsation lnsumon,or a cenifed copy thereof US CJ wM1ich PARK FEE Y N
ecovers sell employee's under this pc.i,.
Policy at GAS-Ep.SYSTEM-1 INC.40UTLETS RECEIPT If
BUILDING DIVISIO51111EES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEEII
❑ Certified copy is hereby famished.
-❑ Certified copy is filed with the citymspeutfon division. GRHASIWNDUSTRL WAS'I'I,INTERCEPTOR GRADING FEE tea#
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SOIISFr
(This action need nm be campletediphe permit is for one hundraJ dollars(Sled) SUMER-SANITARY-STORM EA.200PF. E14ERGY FEE
or less)
I certify that int he peommurnceof the work lit,which this pennh is Issued,I bull WATER II EATER W/VEMDELEM Ik
Out employ my person in any manner an as ,,become�biea�t�th Workers' PAID t
Compensation laws of Califomia. Date r / 9 Z WATER SYSTEM?REA1INC Date R
O z Applicant _ = _ C1p
Z0 NOTICE:T'OAPPLICANT:ILeftnrm ing this Ccnitaatc of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t/J become subject to the Workers Compensation provisions of the labor Code,you mum _
forthwith comply with each provisions or this pchmil shall be Aeemcd invoked. BUILDING FEE
6. (] CONSTRUCTION LENDING AGENCY r` SEISMIC FEE
14
VZ 1 hereby affirm that them is a construction lending agency for the performance of i
O the work(lir which this permit is issued(Sec3097,Civ.CJ A ELECTRIC E
D. ,r Lenders Name PLUMB -
F' Lenders Address QTY. MECHANICAL PERMIT FEE �� it
L) I certify that 1 have read Nis application send sure that the above infomutl is Is '
correct.l agree to comply with all city and county ordinances and state lows relating to PERMIT'ISSUANCE MIiCIf 1.F1?li
building construction.and hereby authorize representatives ofthis city aremaupomhe
V Z above-mentioned property for inspation purpwax. ALTER OR ADDTO MECH. CO 'T COON TA
(We)agme to save,indemnify and keep hamtless Ne City of Cupertino ngainst
Iiabilities,juJgments,costs unA expenses which may in any way nccmeugainmseid City AIR HANDLING UNIT(TO I0,000CFM)
in tonecxptenca of the gaming ol'this pennh. 1 p
AIRIIANDLING UNIT(OVER IB,000CFM)
Signaurcofppplicant/Contmc Dae EXHAUST HOOD OVIDUCT) '
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Og000 BTU) Date Receipt k
Will the applicant or future building occupant store or handle hucarduus material HEATING UNIT(GVHR 100,000 BTU) 'A t
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(a)9 m✓
CI Yes y No VENTILATION FAN(SINGLE.RFSID)
Will the aemna ntor ntunts .building occuptby
Bay Are.Air Quality
Management BOILER-COMP CHP OR IOO,000 BTU) I• UANCE DATE �I
�adoun air comanninunta m Acfincd by the Buy Area Air Quality Management BOILER-COMP(OVER 100000 BTU)
vier! dp
❑Yes jr No NEW N131DLNTIAL MECIi. SQ.
I have.bead the hazardous materials requirements under Chapter 6.95 of the
#\
Caliendo Health&Safety Cade,Sections 25505,25533 and 25534. I understand that oMA p
if the building docs not ethically have a tenant,that it is my responsibility 0 notify the 19
11
ocupant(it 0¢requirements which must No nett prior to issuance'if.Certificate if CITY Iii l'IJ R
Occupancy. r
Owntt ser amhnnuC
d agent Date T ISSUED BY:
OFFICE �.