24997 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- --. PERMIT N°' ^
APPLICATION/PERMIT PING R OJECT ICHANICAL
FICA L
BUILDING DIVISION IW ILUING 1'RfIJE(:T IIIM.NI'IFICA'f10N
4997
BUILDING ADDDRC�SS�:k ` SANITARY NO. APPLICATION SUBMITTAL DATE
� o svMvu\ UNIT# LO'r# f 1���
OWNF SNAME: I PHONE: CONTRA OR'$NAME LIC NO: NIC CONTROL#
C) p� 2S7 10 ZZ)
ARCHITECT GINGER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB F.
PERMIT ISSUANCE ❑ ID ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ZZZ I hereby affirm that l am licensed underprovisions of Chap:er9 bommencingwiN 'aD IPy,O'
00 Serosa 7")of Division 3 of the Business and Profession,Code,and my license is in PANELS
C WF
fall force and affect.
F-O,,, Licnt.Class Lic.# I1'TO200AMPS
:n j y Data Comractar 201-1000 AMPS
,>D�Z ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FI'.FLOOR AREA S/SQ.FT.
O Z 4 a I understand any plans shall be used as public records.
[= �; SIGNS ELECTRICAL
Licensed Professional
�KQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
yO I herebam exempt afr.that 1 aexempt from NCentimeters;e Conactors License law for tate
W 3 a, following union.(Section 7031.5,Bminess asd Professions Code:Any city m county TEMP.METER OR POLE INST.
O; which watches a Permit to construct,slier,improve,demolish,or repair any swttwe
WY;: prior to its issuance,alsurequires the applicant for such permit to file a signed statement POWER DEVICES f-
ty C C O that he is licensed pursuanno the provisions ofthe Contractors License Law(Chapter
9(cnmmencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMINGPOOL LECIM _ VALUATION
XW_m or tM1m he ixcacmpt therefmmand Ne basisfor the IDlegedexemption.Any violation of `
F 7>' Section 7031.5 by any applicant lot a permit subjects the applicant m a civil penaltyof OUTLETS-SWITCHES- URES
�= notn than five hundred dollers(S5W). NEW RESIDENTIAL ELE I
�F� sowne;vella property.ormyemployeeawithwages m theirstalecamperwncan, STO IES TYPECONMUC[
C. w clothe work.and the swmumis not itnendedoroffcred forsale(Sce.7044,Business
I d Pmfessims Code:The Contractor,License Taw does not apply w an owner of DATE
property whohuildsar improves thereon,and whodues such work himse forthroughhfs
own employees,provided 0utsuchimprovementsuenoiintend oroffcred forsale.if. HIOUP RES.UNI IS
however.the building or improvement is sold within one yearofcompletion,thcowmer.
builder wil I have the burden of proving that he did not build or improve for purpose of TOTAL:
scale.). TY. PLUMBING PERMIT
❑ Las the IF Net thepm
ny,70,14,m exclusivelyc0nifiecsngwith CWC:)
Oran mum Q FEE FLOOD ZONIi AI'N
Lmstse ear assert ISrc.7044.Besmear and ywho,lona Cale:)The Cooney,and
icense 4wdfcr sucro h
pplYmawith acofaopeny whored pursuant
tothe Contractors
PERMIT ISSUANCE
who rte Law.far such projon,with a wntrnctor(s)licensed pursuant ruche Costmetsr's
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DGVICE OUTSIDE FEES
Owner SANITARY Y N
Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATIONofcon DEC w1busARN�ON SCHOOL TAX y N_
❑ I"ComfBrm thatlhave aemiifcateorcansenttrof Gmsure,or Lab C.)which FIXTURES-PER TRAP RECFTPTN
Worked Cmmpcnsation Insussre ore cenifed copy thereof(Sec.}gpq,Lab CJ which
PARK FEE Y N
covers all employee's undcnhis pamiL GAS-T:A.SYSTP.M-I INCA OUTLETS � RF.CIi11Tp
Policy p
Company BUILDING DIVISION FEES
❑ C<nifed copy is hereby banished, GAS-EA.SYSTIiM-OVF,R4([A) PLANCHECK FEE
❑ Ccnified COPY is filed with the city inspecuod,ivision. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Ophissectim used not be completed ifthe permit is foronehumors!dollars(Stop) SEWER-SANITARY-STORM Ila.200FT. ENERGY FEE
less.)
I ccnify that in the Mrfomwce sf Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ tray Persian in any tnaame,so as to become subject m the Workers PAID
z CmimeAp,lficunstation Lawsof California. Dene WATER SYSTEMITRE. TING Date Heceiptp
z 0 NOTICE TO APPLICANT,If,after making this CeniOcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT.
F4 hcome subject to the Worker's Compensation provisions ofthe labor Code,you must TOTAL:
a7 Forthwith comply with such rowisimas of this permit shall be deemed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm Nat there is a Construction lending agency,for the perfonrenc,of
L..) O the work for which this permit is issued(See 3097,Civ,C) TOTAL: ELECTRIC FEE
Lender's Name
QU Lender.,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I Certify that I have rand this application and sure that the above information is
F4 comet. I agree 10 comply with all city and county ordinances and since laws slating or PERMIT ISSUANCE MECHANICAL FEE
_ Z buildi-mennswetiand for inspechoip rpssenutives of this city mensr upnmhe
Uz above-mentioned propertyve.indinspection purposes. ALTER OR ADD TOMECH. CONSTRUCTION TAX
(We) dg a 1.nt save,indemnify and keep M1vmlesa the City of Cupcnins against
lincoitieunne mems,cosuang expenseswhich ymanywa ecrueagainstsald City AIR HANDLING UNIT(TO
IO,ODO CFM)
ronseyvenc of the gusting of pe
01 _909
AIR HANDLING UNIT(OVER 10,(IOo CFM)
Si m A am/Conti r Date EXHAUST HOOD(W/DUCT)
PAID
IIul Tal. US MATERIALS DISCLOSURE HEATING UNIT(TO 1011,(100 BTU) Date FCC, #
Will the applicnm nr fumrc building occupant store of handle heurdaus material
as defined by the Cupenino Municipal Conde,ChaaC,9.12,and the l bahh and Safety I]EATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Section 25532(u)1
❑Yes ❑NO VENTILATION FAN(SINGLE RF.SID)
Will the applicant motion,buildin BOILER-COMP 0HP OR I W,WO BTU) ISSUANCE DATE
g occupant use egwpmem or devices which emit
. District?x air cnn:mninums ria defined by the Bay Area Air Quality Management BOILER.COMP(OVER I WgXl,fBTU)
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ.IT.
1 have read the haurdous materials"comments under Chapter fi.95 of the � '
Culifomia Heahh&Safety Code,SectiOss 25505,25533 and 25534. 1 undersand that r�
iftuparhe l dmgdresmotrocaus which
m teman
an tet prin itor
r my to
nsibilitytonotify the �q�
ecupam nl the requi remems which must be met prior to issuunc<uf a Certificate of �P//
Occupancy. AP
Owner or auNonud,gem nate T T ISSUED BY: —" UftFlluvt