24928 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINOHUIIAING-KLM IRICAL PERMITNO. 2 4 9 2
BUILDING DIVISION APPLICATION/PERMIT PLUMIII NG-MF.CHANICAI.
NUIL111NG PNOJECI'IDEMI'IFTCAT'ION
BUILDINGADDRES l /1!S, CPO
ONITg LOTp SANITARY NO. APPLICATION SUBMITTAL DKIE
AM, {�I`/]/'S _\7 PHONE CONTRA R' NAM1f t: LIC NO: '� .#
N/C CONTNOI.p
'N 1 E: LIC NO: ADDRESS � ❑
riaolorm C.1:71
coNT PHONE. BUILDING PERMIT INFO
QTY, GLN.C'TRIC PERMIT .F:
—_ ELEC PLUMB M CH
73&LI 444q Inon
PERMIT ISSUANCE.
LICENSED CONTRAC' R'S DECLARA3'ION gPPL1ANCE5-RESIDIiNTIN, 100 DESCRIPTION
OCz Ihereby affimUhatl am licensed underprovisionsof Chaprer9(commencing with
00 Section]OO "Division 3 ofthe Business and Professions Cale,and my license is in PANELS
y full Tina and effect. , UP'1'O 2W AMPS L �t
FZ� License Class Lic.p
mQd Dale Cuntramor 201-1 AMI
FyN ARCHITECTS DECLARATION SQ,FT.FLOOR AREA $/SQ.FT.
z�y7J- OVERT OA
O z_G I undersmnd my plans shell be used as public record.. 1
FyF-ul SIGNSE E �LM. I e�� I
Yw,❑' Licensed Professional {{{
WfYQ OWNER-BUILDER DECLARATION SPECIAI CIR /M.
x IFE
O a U 1 hereby af(that I am exempt from me Contractors License Low for the
413�y following reason.(Section7031.0 Business and Profmsioe,Code:Any city or county TEMRh ORRT.
whichrequiresa porion to coevou'o,alter,improve,demolish or repair any svucwrc
W}2 prlononsisaaanve,olson,oresme applicant fnsuch pemtinnfileasigectlecorient POWER S
that he is licensed pursuant to the provisions of the Commetors License Law(Chapter
0. 0 9(cmnmcn<ing withSection700mol'Division 3 ofthe Business and PrmfexAons Code) SWIMMING POOL ELECTRIC srr�VALUATION
Section 7031.5 by
ly n, or that he is exempt and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 2,
F 3 G any applicant fora permit subjects the applicant to a civil penaltyof W_0
5 not mom than Eve hundred dollars($500).F$ ❑ I,asownerofthepropcny,ormyemployeswiihwagesaztheirsoleconNEW RP.SIDI:NTIAh IA,ECTR —SQ.SQ.IU'. STORIES PE CONSTRUCTION
�
L'3— wiildm the wmrk,andda slm,lure ianml in¢ndeJ oroffereJ Tarsal<(Sec.]044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who huildsorimpmvesmercon,and whodoessuchwork himself'orlhrougbhie OCC GROUP RES,UNITS
own cmployees,pmvided that such improvementsearrot imendedoroffcred Tarsale.If.
however,the building or improvement is sold within one year of completion,the owner- o
builder will have the harden of i n vin,thin he did not build or Improve no paHax of
sale.).
❑ Lasowneroftheprop,ny,amexclusivelyconvacdngwOhlicenwdcommcimto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
oomvuet the pmjcat(Sec.7044,Business and Professions Cade:)'Imo Contractor's _
Licensel.aw doesnot applyto anownerofpmperty whobuildsor improves lhercer,and PERMIT ISSUANCE
who contracts forsuch pmjccts with acmntromm(s)licene,dplarmantto the Commctors
License Law. ALTER (EA)) FEF SUMMARY
„r ❑ I nm exempt under Sec. ,li X P C for this reason BACK FLOW PROTF.C'1'.DEVICE TSID:IJ3F.S
SANITARY Y N
Owner Duce RECHIPTk
DRAINS-FLOOR,ROOF,ARBA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX VN
❑ Ihereby affimrlhall heveacertifi[am of ronsem mealf-insure,orecertifieme ofRECHIPIN
Worker Compensation lnsurnmenracenifiedcopythereof(Sec.3800,Inb C.)which RFS-PER TRAP PARK FEE Y N
rs all employees under this pemtit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPTp
Policy tl I BUILDING DIVISION FEES
C y GAS-EA.SYSTEM-OVER 4(EAI PLANCHECK FEE
Certified copy is hereby furnished.
❑ entified copy is filed with the city inspcaion division. GREASE(INDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF IMEMPION FROM WORK MS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section need nal be completed if@c permit is forma,hundred dollars(SI00) SEWER-SANITARY-STORM EA.200PP. ENERGY FEE
ode's.)
I certify dist in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compereationlnwsof Califiando Date WATER SYSTENUTREATING Dot, Receipt#
O z Applicant
zNOTICE TOAPPLICANT:If,after mrising this Certified,ofExemptim,you should NEW RES I D Ill JAI.PLMIL SQ.FI. IOTAI„
� �i becminumbjcm to the Warkefs Compensation provisions of the Labor Code,you most
, forthwith comply with such pmvisions or this Permit shall bedecmed revoked. BUILDING FEE
6J] QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
C) 01 hereby uffmm that there is a conswction lending agency for the perforators of
the work for which this Pemtit is ismed(Sca 3099,Civ.C) TAI /ate ELECTRIC FEE 1
Lender's Name
u-' F Lender's Add., QTY. MECHANICAL PERMIT FEE PLUMBINGFEL• 2 ...�.
>1LU17 1 certify That 1 have read Ili,application and elute Ihm the above infomlmino is MF:CIIANICAL PEE
� correct.l agree to comply with all city and county oninances and state laws relating to PERMIT ISSUANCE
t14 building construction,and hereby almoner representatives ofthis city to enter upon the CONSTRUCTION TAX
V above-mentioned property for inspection purposes. ALTF,RORADDTO MECH.
(We)agree to save,indemnity and keep harmless me City of Cupertino against
Iiabilities,judt cots,cases and expenseswhichmeyin my wayaccrueagainst said City AIR HANDLING UNIT(TO 10.000CFM)
d the mtin oft pe I
AIN HANDLING UNI'P(OVER 10,000 CPM)
Signature of pplicant/Contriefor Date EXHAUST HOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.00)BTU) Dice Receipt#
Will the applicant or furore building occupant entre or handle hazardous material
v JdineJ by the Cupeninn Mune
icipal Croda,Chapcer 9.12,anddthe Heullh and Safety I HATING UNIT(OVER I00,0(1(1 BTU)
Cede,Section 25532(y?
❑Yes 13 No VENTILATION FAN(SINGLE RESID)
ISSUANCE.DATE
Will the a licanl or fuwrebuiltlin fusee mrdevitts which coil BOILER-COMP(311P OR 1(g),(%p 8'I'll)
pp gby then qu Air
hamrdous air cmmaminama az defined by the Bay Asea Air Quality Management TOILER-COMP(GVHR 100,000 BTU)
IsnlcR
❑Yes 0N NEWRF_SIDENTIALMECH. SQ.FT.
1 have mail mo
the mountains materials requirements under Chapter 6.95 of the
California Health&Solely Code,Sections 25505.25533 and 25534.1 mdersutnd that }� y
if the building does not currently have a nonan.that it is my responsibility to nmifyme P A
occupant of the requirements which must be met prim to issuance of a Certificate of
Ove"Pency.
Owner or authorized agentUmc ISSUED BY .
OFFICE GIIV ur 0)f rnloitk,
p - r
ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATIONJE
FI
• ��' • VALUATION V'1
Aoo Ess Pi
0 t3A7�4vstVA �R4�k � R�E SUMMARYco 'r ACTONsNAME - CK. .DDRESS -
EEQTS. ELECTRIC PERMIT �'FEEUTLETS-SWITCHES-RECEP LIGHTINGFIXTURES
PPLIANCES-RESIDENTIALG • ,`�PANELS CAL.SIGNS ASIGNSTRANS.' , AL' �'-
SPECIALCIRCUIT '/EMP.METER OR POLE INS.- PERMIT VALIDATION -
MOTORS.,- SEE FEE SCH,
0 SERVICE CHANGE
4z z
TOTALend �! l/CLj�
I �j
W DTV. PLUMBING PER SSUANCE DATE
MIT- tFEE BLDC. ELECT. PLO. MEC..
0 2 ALTER-DRAIN&VENT-WATER IEA.1 ❑ ❑ ,�,� ❑
V O BACK FLOW PROTECT.DEVICE
LL F-
O w DRAINS-FLOOR,ROOF,AREACOND. ' �}
1 } a FIXTURES-PER TRAP - �,•,�"'
N
GAS-EA.SYSTEM-11NC.40UTLETS j 'r
S)
' V u"AS-EA.SYSTEM-OVER 4(EA.1'
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS.11NC5 V,B. pp�� pp
LAWN SPRINKLERS-OVER 51EA.1 r A
SEWER-SANITARY-STORM EA.200R/ p�ny
WATER HEATER W/VENT " �I�MI '1 y �^w3
WATER SYSTEM - Qry'!s55 n .1.1 yl� ie .
�,_ •"� WATER TREATING EQUIP. VI Ill ur Lour Q11'I.IIY1,/ 'lIQ
-• ,�• QTY. MECHANICAL PERMIT FEE
1 ALTER OR ADD TO MECH. ,y
' APPLIANCE
AIR HANDLING UNIT ITO 10=C.F.M.)'
AIR HANDLING UNIT(OVER 10=C.F.M.)) `
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T,U,)
VENTILATION FAN(SINGLE)
r BOILER-COMPI3 H.P.or 100,000 B.T.U.I �
BOILER-COMPIoW„ICDDDOBTLIISEE FB[BCH.
-- —_
T TALI I � .
111