24976 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-CLEa A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECIIANICAL, n R 9 7 6
ii� IIUILDINGIROJECI IDEN'TIFICA'TION L
ILDIN(1 ADDRESS: SANITARY NO. AI'1'LICATIOSU
B
J
MITTAL DATE
C
-ZZ-Lp•S UNIT# LOT k Cal 7"l
NERS NAME: PHONE: C NTRACTOR'S NAME: LIC NO: l
-LZsv II NIC CONI'ROLN
RCHITECT/ENGINEF.R: LIC NO: DRESS: -Il.C4 ❑
CON'TAC'T': PHONE: BUILDING PERMIT INFO
QTY. ELEC'T'RIC PERMIT FEE
BLDG ELECT LUM MECII
PERMIT ISSUANCE 0 X ❑
LICENSED CONTRACTORS Perfidious
a APPLIANC[S-RCSIDEN'flAh 1"" IiS
0Cz [hereby affitmtbat l am licensed underprovisionsofChapter9(commencing with .`{••/la�/__[_\'_'•OB D 11N����\/-`y''yy—[`'r"`—////l,"`_'l�
WOO Section llXq)of DivisionJof the Business and Pmfesslow Code,end my Llano is In PANELS
KF. full fame and efra
Fye LiccneeC es � Lic.# tiJ I At--S; UPT02MAMPS
vs60. IEC'TS CTSD T_ 201-IWAMPS
ZOy— ARCHI'TEDECLARATION OVER itak AMPS SQ.Ff.FLOOR AREA 5/SQ.FT.
I understand my plans shall be used as public rtrnrds.
r vi�'Ly] SIGNS FLECI'RICAL
Q j Licensed Professional OWNER.BU1LDER DECLARATION SPECIAL CIRCUII/M' ISC. ed f�G�
x�'OZ. I hereby affirm that 1 am exempt from the Contracmis License Law for the1 1� �, T
t+13�m feri-ingrativn.(Seeded 111315,BusinessunJ Professions Code:Any city or county TETE
EMP.MR OR POLE INST. 1111
eo�� wM1ich rcquiresv pcmtit to construct,alttt,improve,JemnlisM1,nr repairanystrvmu¢
�aW'2 prior to its issuance,also requires the applicant[or such permiuolileasigned statement POWER DEVICES DA E
W e5 00 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a e� 9(eo..mullein,Milt 10010)nf Division Jofihe BusinessunJ Prnfesxinns Code) SWIMMING POOL ELECTRIC VALUATION
yYj_y or that he is exentpuherefrom and the basis for the alleged exemption.Any violation of
F^zQ
Seel ian7031.5by:my split icunt for v permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
Sa not more than rive hundred dollars($500). NEW W R&SIDINTIAI.ELECIR _SQ.IT.
ago ❑' I,asawnernftheproperly,nrmycmployceswith wages as thcirsulecomgidenion, STORIES TYPECONSTRUCHON
22 willdarhe work.and the swcture isnot intended proffered fursale(Sec.1000.Business
and Pref cesinrn Craft:The Contractor's License Law dues not apply men owner of
progeny whobuildsarimprovesthcrmn,aadwbodoes such work himselfonhraughbis
own employees,providedthat such impolvemcntsme no,icandedoroffered forsale.If, OCC.GROUP 11 RE.S.UNITS
however,the building orimprovemem,is suld within nneyearef completion,the owner- l'OI'AI
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner ofthe progeny.um exclusivelycommcting with licensed epnaanonto QTY. PLUMBING PERMIT FEC FLOOD ZGNE ANN
conduct the project(See 7044,Business and Professions Cadet)The Carlin lis
License Law does not apply toanownerofpmpeny who builds orimproves themon,and PIiRMI'I'ISSUANCIi atial
whocontmctsforsuchprojemswlthaeon"ctot(s)licenudpunuanuothe Convacior's ALTER-DRAIN&VONT-WATER EA
License Law. ( ) FEESUMMARY
❑ lana exempt under Sec. ,B A,PC for this reason BACK FLOW PROTECT.DEVICE. LH'.IDE -EES
SANITARY Y N
Owner DatcDNAINS-FLOORROOPAREA,CONIRECEIPT#
, .
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX Y_N
❑ Thereby infirm thatl havevicenificate of comrnno selGinsure,ore cenifwm of FIXTURES-PERTRAP RF.CEII'IN
Wnrken'Cnmprnsatiun lnsunnce orecenificd copy thereof(Sm.38W,Leb Q)which - PARK FBI; Y
covers all employee's under this permit. OAS-FA.SYSTEM-1 INC.4 OUTLI?'rS - RECEIPT#
Pal'y M BUILDING DIVISION FEES
C pony-- I� GAS-EA.SYSTEM-OVIiR4 HEA) PLANCHECK FEE
nified copy is hereby famished.
❑ Certified copy Is filet]with the ally inspecrimt divixion. GREASP./INDUSI'RI,WASTE INTERCEPTOR GRADING FEE
CERT IFICATE OF EXENPTION FROM WORKERS' GRF.ASHTRAP SOILS FEB
COMPENSATION INSURANCE
phis section need not he completed ifihe permit is fat one hundred dollars(E 100) SEWER-SANITARY-STORM EA.20017. ENERGY IT-E
or less.)
I certify that in[lie performance of the work ha which this permit is issued,l shall WA A
TER W/VF.NUU".ECR
not employ any person in any manner so as to become subject to the Workers' PAID
Cnmpematianl.awsnf Culifpmio. Date ATERS TEMlUU1 TING Da¢ Rmeipt#
z z Applicant
p NOTICRTO APPLICANT':If,ager makin thisCmifmate of Caemn TOTAL:
g rod,you multi N ESIDI'NTIAI,PLMB. SQ.PI'.
z VJ becomeh compo the Workers Compensation prmisioroofthe Labor Code,you must -
fanbwitb comply with such provisions or this permit shall be dttmcJ resolved. BUILDING FEL'
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the perfommnce of TO ELECTRICFEE
U p the work for which this permit is issued(Sec.3091,Civ.C.)
0 Lenders Name
Lender's Addmss Q'I'Y. MECIIANICAL-PERMIT PEE PLUMBING PER l�
1 cmify the,1 have read,his application and state that the aMsce infer a armn is
mnect. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
F-t 0,, buddingconstruction,and hereby authorise upresentatives of this city to enter upon the
U 7 above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
G7 (We)agree m save,indemnify and keep hefmlcss,he City of Cupertino u,mrsl
liahilities,judgment.costs andexpreass which may in any wayecemeagainst id City AIR HANDLING UNIT(TO 10,0010 CFM)
in mnseyvena he ting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Iq
Signature
ofAllplIfFenanContractur I `D.mr EKFIAUSTHOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE I MATING UNIT(TO 100,00)BTU) Date Receipt#
Will the applicant or future huilding oceepant store or handle hazardous material 1IL'ATING UNIT OVER 11010,1X)0 0'I'U) TO'T'AL:
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health lend Safety
Cade,Section 25532(a)1
11 Yes Cl No VENI'l1.ATION FAN SINGLE RUSID) tals'
Will thea applicant or futumbuildin cuamuu lei BOILER-COMP CHIP OR 100,000 BTU) ISSUANCE DATE
pp gby p Area
p Air Qudcvic Management PAI
Dlauirptu air cnntuminnnH as defined by the Buy Amu Air Quality Mnnagemmt BOILER-COMP(OVER 100,(10)RTI[) PMI y'
DisWn?
❑Yes ❑No NEW RESIDENTIAL MECH SQ.FT.
I have,cad the lassitude.,materials relairemema made,Chapter 695 of the APR 15 Egg
CaliforniaHeahh A,Safety Code,Sections 25505,25533 and 25534.I understand that
if the building doesnot currently hot,.reseal,that it isrny re pmmihilay to lady the CITY U� UUP ['Chill
occupant of of the requirements which must be and prior to issuancenifi
of a Ceeate of
Occupancy.
Ownentr authorized ngen, Date TOTAL: ISSUED BY: