24523 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - 1 - ..,C I RICA PERMITNO.
BUILDING DIVISION 'IA .
PPLICATION/PERMIT PLUMBING-MECHANICAL.
II /� A 4 2 3 r^/�
BUILDING PROJECT IDKNTIFICA'riON 2
BUILDING ADDRESS: e`�y�r��" �►' SANITARY NO. APPLICA^TION SUBMITTAL DATE
I� �/�\�Y�+ �� LOT If �i(��2
OW t SN
PHONE: CO R:SIILIC NO:
I : 1 N/C CONTROL If
Q 11.1 P sem-
• ARCF1'1'IiGT/F:N NEER: LICNO. c ADDRESS: ❑
J
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
.�Il,. IA-/ , ELECT PLUMB ME❑CH
BENS iv PERMIT ISSUANCE
LICENSED CONTRACTOR vidns DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIFfION
tpyrg IhSection Mader o that Division
am fiansed Businss and
Professions
Coer v(co mmencing with
FOO full focetand)effD'Itviaien3ofthe Business and Professions Code.and my license is in pAN1]S
C
FZ Limn cC s Lie.# 3s / L UPT02W AMPS
m=y
Date Conuactor 201-IOIIIIAMPS
f =oo ARCHITECTSDE ATIO SQ,FI'.FLOOR AREA . S/SQ.FT.
ZOy— OVER 1011(1 AMPS
oz-0 I understand my plans shall No used as public records. ��♦ ♦ /�
F.yF; SIGNS ELECTRICAL /`rJ1fi1 b(�//,
a Licensed Professional
aG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOaF I hereby affirm that I am exempt from the Contractors License law for the
1+13
O{Lg llow
fning on.m.Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which terplires a permit In construct.alter,improve,demolish,or repair any structure —
prior hs issuance also requires the applicant for such permit le a signed statement POWER DEVICES
nm FileJ
OO that he is licensed pursuant to the provisions of the Counselor's License Law(Chapter
9mfineta6ng with Section'I00()ofDlv1,ion 3of lire Balmealthd Professions Code) SWIMMING POO(,ELECTRIC I
.,y or that he k ewear t,hembo.endthe basis fnnhe alleged exemption.Any violation of OUI LC'1'S-SWI'1 CITES-FI%TURES
CZi
Section 7031.5 by any applicant fora permit subjects theapplleant ton civil penalty of
not marc than rve hundred dollars($500). NEW RESIDENTIALULECTR FT.
W ❑ Lnsownmoftheproperry,ormyemplayees withweges0sthcirsolecompensation, —SQ. STOR S I'YPH CONSTRUCTION
a will do the work,and the swttuc isnot intended mothered]fmsale(Seo.704,L Business
and Professions Cale:The Contractor's License Law Jas Or apply m an owner of
properly wbobuildsorimpmvesthereon.and whodoesta ch workhimselfonhrough his
own employees,pruvidedthat such imprrearentaere not inhoshderoffered fnsale.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearof completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I.asowneroflhepmpeny,amexclusivelycolnmetingwithlicenmdcontmctonto Qom'I
PLUMB IN I FEE FLOOD ZONE #pry
construct the project(Sec.7144,Business and Professions Code:)The Committees
License Law does not apply to an ownerofproperty who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with acontracmr(s)licensed punmmnt to Commences
LicenveLaw. ACI'F;N-GRAIN&VI!NT TER FEESUMMARY
❑ l um exempt tinder Sec. B&P C for This reason HACK FLOW I'k0'I'; DF ICF OU'ISID,19:4
SANITARY Y N
Owner Date RIiCEl I T#
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,R PA ND. SCHOOL TAX
ElY N
I fina l have a cenifwm ofcomand to eelbinwte,oracenilicme of kF.CEll9'#
Worker:Compensation lnsuranceor a ceNfeal copy thereof(Sec,38(X1,Lab C.)which JTXTURES-PER'IR PARK TLE Y ,
coven ullcmpinycis under lois permit. GAS.EA.SYSTP.M-I INC.40 TS RECEII"4
Policy M BUILDING DIVISION IM-
Cnmp:er - GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE /
❑ Certified copy is herebyled furnished.dre city
Certified copy I CERTIFICATE
We city inspection on divisi n.
W GREASEnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CF.RTIFlC OPEN COMPENSATION
FROM WORKERS' GRFASIVIRAP SOILS FEE
COMPENSATION INSURANCG
(This section need not be completed if the permit is for hundred dollars(S100) SEWER-SANI'1'AkV-STORM FA.200Pf.
or less) ENERGY FEE
I cerily that in the perfonnanceofthe work for which this permit is issued,filial WATER BEATER W/VENT/ELECTR
aal employ any proven in any manner so as to became xobject to the WorkersPAID
z Cntnpennation Law,el'Calirornio Date WATERSVSIHMn'REATING Ham eceiptp
NOTICHTO APPLICANT:IL afteut
r making this Cedifcc of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. .p
HN become subject o theWorker's Compensation provisions ofthe Tabor Code,you must
7 fannwitb comply withsuch provisions onhis permit shall be deemed invoked. BUILDING FEE
0. 0 CONSTRUCTION LENDING AGENCY SEISMIC1.
7Z I herehy affirm that It.is a construction leading agency for the serfarmmce of
U O the work for which this Fern;,is issued(Sec.3(19],Civ,C.) TOTAL: ELECIRI ITa
lander,Name
QU PLI FF.6
Lender's QTY. MSCI IA PERMIT FEE
U I certify that 1 have read this application and state that the above information is
correct.l agree in comply with all city and county romances and state laws relating to PERMIT ISS UANCH (CAL FEE
buildingemoruchon.and hereby authorize representatives oflhi.s city to enter upon the SIRUCTION TAX
U Z above-mentioned properly for inspection purposes. ALTER OR ADD TO AllL
(We)agree to rose.indemnify and keep harmless the City of Cupertino against
liabilities.judgments,ends and expenses which muylnuay wayoormeagainstsaid City AIR HAN DLING UNI'I'G 010,000 CFM)
I the gram, (this pearan.
�` L /., AIR HANDLING UNIT(OVER 10,(k0CFM)
nuturc nl Appl'Imt/C mramarJ �� Date L F.XIIAUS'I'GOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('TO 0),"BTU) Dat Receipt#
Will the applicant or future building occupant store or handle Interpol material HEATING UNIT 100,0(10 RTU) TOTAL;
as definul by the Cupertino pal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(0)^
❑Yes VENTILATION PAN(SINGLE RESID)
Will theapplicantorNmmbuildingoccupmtuseequipmentordeviceswhichemit
BOILER-COMP CHIP OR 100,00a)9TH) IS ANCE DATE
bwurdaus air contaminers as defined by the Bay Area Air Quality Management
DlstdmY 0,000 BOILER-COMP(OVER 10BTU)
❑Yes )ILN -- NEW RESIDENTIAL MECH. SQ,FT.
1 have read the hazardous materials requirement,under Chapter 6.95 of the
California Health&Safety Code Sections 25505,25533 unit 25534. 1 understand that
If the baildi g does ova curt early have a sham,that it is on,rcslnn,IFllity to nmifythe
n
farm u mgmama;, wn must h mel h muprior m I to of a C"'ficme or
%U�„n Cd ii,em / Z Y/ Date TOTAL: ISSUED
OFFICE