24961 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-FUT RI AL PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICALG NT
-
./�
BUILDING DIVISION
BUILDING PROJECT IDEIFICATION �,4 �
BUILDING AD ISS: SANITARY NO. A11'P`LICA'IIIIONN SUBMITTAL DATE
. UNIT# LOT#
ERS NAME'7N� It JA 'HONE: CONTRACTOR'S NAME: LIC NO:
O`�
NIC CONTROL#
ARCHITECT/ENGINEER: UC NO: ADDRMS: ❑
CONTACT: PHONE: wR 1 :' tTa. t ' Sk BUILDING PERMITINFO
TY %v ELFGrRIC PERmrr EEE
- 'E""* •� BLDG ELECT PLUMB MGCIi
PERMIT ISSUANCE
LICENSED COadorde'OR'g DECLARATION gPPLIANCES-R&SIDENTIAL ROE
OKZ Iherenyaf'Divi, tl umlicansedinss it mfiasnfChapter9(commencingwith
LDOO Section'](100>ofnivia on3onne Business acts Proressinns—C�d1e.andmyliunscisin PANELS JS tfkA .F�—
�zWfuclen rcc end effc ' Z • UP TO 200 AMPS 1 w� sfyg '�n'
<ZIy s lass Con v R'V
wjy Dale ComrsCmr 201-1000 AMPS
Z Or`�i,Z 11 L4 I CHITIiCTS DECLARATION OVER 1000 AMPS F@rRE#iITR AIEa _ EISQ.PI'.
O Z—❑w 1 undersmnd my Ela s shall be used as public records. " /l N
S=C J SIGNS ELECTRICAL
SSy 04,
Licensed Pmfensinnal � - I,
��a OWNER-BUILDER DECLARATION SPECIALCMCUIT/MISC. E ,(las(`
#0.x,OO'F 1 hereby affirm that 1 am exempt from the Contractors License Law for the
F i!101 or following rcawn.(Section 7031.5,Business and Profexsio is Code:Any city or county TEMP.METER OR POLE INST. — 2
o ti which requires a permit to construct,alter,improve,demolish,or expeh any swc[ure DA
o'Y2 prior to its issuance,,Jsorcquirestheapplicantforsachpc ttofileaslgnedsmtement POWER DEVICES
EMO tha[he is liccnsalpmamsmt to the provisin,a of the Commcmla License Lew(Chapter
as K 9ournmencin with Section 1(1(10 of Division 3 ofthe Business and professions Cale SWIMMING POOL ELEC7DUC
Kos gwi ) ) VALUATIOy
w S2. or that he is exempttherefrom and Ne basis for the alleged exemption.Any violation of FIXTURES T
L ZKQ, Section 7031.56 an applicant for Permit the applicant a civil penalty of OIITLEfS-SWITCHES-
y'y Y Y re R0). 1 pP P Y N. I
p 10 can roftheve mrc Ay,do[,rmyompl NEW RFSTDENTIALELECTR —SQ.FT.
ypro n❑ LmownernOEmit these uy,mmyempended whffered as Meirsolecompematon, STORIES 'TYPE CONSTRUCTION
will dotbewons Coe he Careisnor',Lienee Law
not
in an Business
and Professions Code The vcs t emon,License Lew does not apply 1f rt owner of
tomemproperty wyces,pdsorimprovesth improandwnsam not intended
mothfonh battle.If.
b wemr.thees,pingor improvement iovementsam not earrocompletion,fmsale.q OCC.GROUP RES.UNITS
aver ill have ti a bur en ofproving
sat he within one year ori prove om t purpose
r-
b le.). will have the burden of pmving that he did not build or improve for purpose of 'TOTAL:
sale.). -
❑ I,usowaendlhepro)xny,am exclusive( ronin NlicensW contracmrs[n QTd': r ?,',PLUMBING PERMIT,,, .PGE 10,OOD'ZONE APN
y con gwi rot Fy/
onxwa the pros,(Sec.ortno Business and Professions Cafeq The Contra,and PERMIT ISSUANCE
License Lawdoe notapply jects with
acofpropcny whobuildsorirnurn rxvctomeContrcend S
who contracts fncshmM1 pmjectswi,h ucnmmemrts7licenscl porsunm tomeContractor's ALTER VENT.WATIM(FA)
License Luw. EEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE? O ,TDF. .I•
SANITARY YN
Owner Data RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOON.BOOK AREA,COND. SCHOOL.TAX YN
❑ Thereby affnn thatl havcacenificate ofconsem ruse((-insurc,aaceni0cam of RECEIPT#
FIXTURES-PER TRAP II,,
Workerx'Compensmien lnnurance orucertifed copy thereof(Sec.3u00,Lnb CJ which 's/ PARK PCI: YN
coven all employee's under his permit GAS-HA.SYS1TM-I INC.4 0UTLETS RECEIPP#
Policy 0 BUILDING DIVISION FEES
any
0 CanlEul copy is hereby famished. GAS SYS'I'I?M-OVER 4(EA) PLANCIIECK PER
en
❑ Candied copy is filed with the city inspection division, GREASRnNDUSTRL WASTE IMERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
('Nis semionneednm becompletedHiles pound,is ficome lonlreddollars(EIW) SEWER-SANITARY-STORM EA.200111'. ENERGY ME
cutest.)
I cenifythnt in the perfomance oflhe work horwhich Ws Permit G exhW,I shell WATER HEATER W/VF.NT/ELECfR
not employ any person in any manner so as to become subject to the Workers' 7, #gip
Componsmina Lawsof Califomis. Date WATER SYSTENVIREATING Date Receipt If
Q Z Applicant
'zo NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
,r 4 Irocome subject ro the Worke/s Compensation Provisions a fine Labor Code.you most
ce > forthwith comply wind such provisions or this pcnn,itshot]bediscussed revoked, BUILDING PEE 35=�
LU Q CONSTRUCTION LENDING AGENCY SEISMIC FEE a S
1 hereby aflinn that there is a construction lending agency for the perfmmmce of TOTAL: ELECTRIC FEE
C.) Q the work for which this Permit is issued(See309"1,Civ.CJ _ Zd-
UnderaNdme - v PLUMBING FEE 76
0 F Lendeln AJdree Q'fY,:•i'y j {MF.CIIANICAL,PBRMIT-� PGL
W 1 candy that 1 have read this application and state that Ne above information is `
Gcorrect.l aura to comply with all city and county ordinance and Bate lows ralming1. PERMIT ISSUANCE ,111 MECHANICAL Fill:
building construction,and hereby amhodze represenmlivesofthis city to enter upon the CONSTRUCTION TAX
V Z above-mentioned pmpcny for inspersion purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep a the City of Cupertino against
liabiliti ,' J toss expercew ' manyweyacerueauainstsaid City AIR HANDLING UNIT CIO 10,000 CFM)
inams n egr d of,bele i, V_..a/
CG AM HANDLING UNIT(OVER IO,oO CPM)
5 m re r Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Wills applicant or future building oecupsem store or handle hazardous material HEATING UNIT(OVER 100.000 Is'1'U) TOTAh: /0 J7S
asdefined ythc Cupenino Municipal CWl.Chapter9.12.andihe Helthand Snfcly ,,'�11
Cade.Section El25cs32(s)? E)No VENTILATION FAN(SING LE RMID) 3' (w
ISSUANCE DATE
Willtheacontanmrfumre building by
equipment Quality
Management
BOILER-COMP(3HP ON 100,gq BTU) P A 9
hazardous air contaminants ss defined by the Bay Area Air Quality Management
District? BOILER-COMP(OVER 100,01S BTU)
oo o w`
❑Yes ❑No NEW RESIDENTIAL MF.CIL SQ.FT. APR (y N�V
1 have real,he hamnlous materials rcquiremenm under Chapter 6.95 of the
CCaliforniaIiealth&Safety Code.Sections 25505,25533 and 25534.1 understand that '/�
if the building does nmcmrenty have a reason.that it is my raspoeibili,y to notify the 'VII T Vf QUf t1YI11VV
occupant of the requirements which must be met prior to Issuance of a Certificate of
Occupancy.
Owner or nuthorizod agent Date TOTAL: ISSUED BY:
H
PROGRAMA DE
HOUSING
PRESTAMOS PARA
• REHABILITATION • i n
= W1 REPARACION DE
LOAN PROGRAM
VIVIENDAS
Offered to qualified owner-occupants of single-family Ofrecidos a Buenos-ocupantes de cases o
i
residences or condominiums. Rehabilitation work condominiosoncualquiervecindariodoIsciudad.Se
includes new roofs, kitchens, bathrooms, wiring, prestadineropara reconstruirtechos,cocinas,banos,
plumbing, termite work and room additions where alambradoel6ctrico,plomerfa,yreparacionescuAndo
there is overcrowding.• Loan amounts vary los dartos hen sido causados por Is incursion de
according to rehabilitation needs. ague, o por Is infestacf6n de polillas; adiciones de
cuanos cu6ndo haya muchas personas viviendo on Is
misma residencia.La cantidad de el pr6stamo depende
de at monto de Is reparaci6n.
Household 3% Loan 6% Loan N6merode Prktamo Prestamo
sin Income Limit Income Limit Miembros at 3% Llmite at 6% Lfmlte
. en to Famllla de Ingresos de Ingresos
1 $19,650 $27,000 1 $19,650 $27,000
2 22,450 30,900 2 22,450 30,900
3 25,250 34,750 3 25,250 34,750
4 28,000 38,600 4 28,000 38,600
5 30,300 41,700 5 30,300 41,700
6 32,550 44,800 6 32,550 44,800
7 34,800 47,850 7 34,800 47,850
8. 37,050 50,950 8 37,050 50,950
Call the Menlo Park Llamar al Departamento de Vivienda y
Department of Housing and Desarrollo (Department of Housing and
Redevelopment Redevelopment)
858-3414 858-3414
1100100011 ('1111"ll"On 00010000
s::$:�a„on.5< , o, v.; :. :,.<r..c