24505 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- .LF.CI'RICA L FERMI'I'NO.
APPLICATION/PERMIT PLUMBING-MECBANICAL. 24505
� q C 0 C
BUILDING DIVISION BUILDING PROJECT IDRN'PIF'ICA'I]ON G LL J J
BUILDING A(DURBSS: SANITARY NO. APPLICATIONSUHMTFI'ALDXEE
V V ✓ C UNIT'# LOT# ��
f' C R LIC NO: It
�r►lVi N/C CONTROL#
RCI ITECT/ENGINEER: LIC NO: D RESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Q'I'Y. ELECTRIC PERMIT FES
BLDG. ELECT PLUMB MF.CH
EFRAIN ISSUANCE ❑
LICIiNSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. )IDB DESCRIPTIO
Oniz Iherrby al'@m that l not licensed under provisions ofChaptm9(communing with _ ^�
POO Section 7")of Division 3 ofthe Business and Profiesoons Code,and my license is in PANELS G ;a
W 41C fall once and art..
<ZW License Class Lic.# UPT0200AMPS
w'<y Data Contractor 201-LIMO AMPS
Z UON ARCHITECTS DECLARATION SQ.FI'.FLOOR AREA 5/SQ,FT.
OVER IBM
04—Q y. I und.rn:n:J my glare shall he used as public recnnla.
(•yF2wSIGNS ELECTRICAL
s ldmnsed 14olessinml
OWNER-BUILDER DECLARATION SPECIAL CIRCULI'/MISC.
Oaf 1 hereby affinarn.(Se ti that 1 oat exempt from the Contractor's License Law for the
ty3LLy
>-; following to co3L5ct,alua,imp Profusionsh,or Any city or county TIiMI'.MF:'1IiROH POLE INST. /�
which innirms npemtit tocanstn],a cher,improv.,dennarilt mrepair on,d swcmre
}0 paortoslicensed personal 1.tit m.,isinans forachpetmiuo Ble.signed statement POWER DEVICES
M �pK that he is licensed pursuant m0e provisinm of the Comrvaor's Limnse Law(Olapter
a X.0. 9(coimnencingwithS tion➢oo0)of Division3ofthe Businessand Professions Cede) SWIMMINGPOOLELF>CTRIC VALUA'BON
W;'^y or that he is exempuhimfnomand the basis far the alleged exemption.Any violation of OUTLIiTS-SWITCHES-FIXTURES
yza Section 00315 by any.,he.,far a Peron subjects the applicant lr a civil penalty of
C^�^� not elhan five hundoeddollurn($5W). NEW RESIDENTIAL.ELECfIt_SQ.Ff.
Fo I,asowncmfthepmprty.ormyemployceswithwagesasiheirsolecoinpensation, S'I'ORIIS - TYPECONSIRUCTION
w the work,and the structure is not intended or offered for sale(Sec.l0a4,B marress
d Profess re Conde The Conlowica x License Law does not apply to an owner of
ropery who builds or improves thereon.and who does such work himselfor through his OCC.GROUP RES. NITS
nemp]oyecn.pruvided thotsuch improvements omnot inlendedoro(fered forsale.If,
however,the building or improvement is sold within one year ofemmpletim,theawner- _ar
builder will have the burden of proving that he did not build or improve for purpose o1'
sole.).
❑ Las ownerofth.property,sem enclusivclycanvndinswithlicenxedcnnvaeurs to QTY, PLUMBING PERMIT FEE FLOODZONE APN
consumer the project(Sec.OBW,Business and Professions Cade:)The Comroaols
Liccmu Lawdnesmam,ply manownerofpmpertywhe buildsor Improves ilmreon,mal PERMIT ISSUANCE
whocom acts fm such projects with sommo airs)licensed pursuant to the Commences
License].aw. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I em exmnpt under Se<. ,B&P C for this reason BACK FLOW PROTECT DEVICE - O PSIDLFF.IS
SANITARY Y N
Owner Dam RECEIPI'N
DRAINS-f1.00R,ROOF,AREA,COND.
WORKMAN COMPIiraw of ONDECLARATION SCf1001,'1'A% Y N
❑ Thereby afford that have acenificam of mnunnnself-imurt,oracb C.)w ich FI%TURFS-PER TRAP RECEIPI'p
Wnrkere'Cnmpensation lnsurvnueout e.nlOeJ copy them d(Sec.3B00,l.ub CJ which PARK FEE Y N
corers all employee's under this permit. GAS-11A.SYSTEM-1 INCA OUTLETS RBCEIFI'N
Policy# BUILDING DIVISION FEIN
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cenlfied copy is hereby famished. -
❑ Candied copy is filed with the city inspection division. GREASE/INDUSIRL WASTE.INTERCEPTOR GRADING PER
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not ire completed Bite permit is furore hundred dollsrs(SIM) SEWER-SANITARY-STORM IEA.200FT. ENERGY FEE
or lwa)
Icenifyffim in the gerfonn..ftit work forwhich this permit is issued,,shall WATER HEATER WNENT/ELEC9R
nm employ nny person in any manner so as to became subject to the Wo kers' PAID
Az Compcnsmion Isws of Cnlifomia. Data WATER SYSTEM/PRRATING Uwe Receipt p
O O Appllennl
NOTICE TO APPLICANT:If,after making this Cctifieure of Exemption,you should NEW RES]DENTIAL PLMIL SQ,FI'. I.OTAL:
ubecome subject to the Worker's Compensation provisions of the Labor Code,you most
a , funhwith comply with such provisions or this permit shell be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SIBSMICFEh
5 I hereby uffmt Thal there i.s a cn,nation lending nsency for the Performance of
U the work for which mis gem n is heated(Sce.3W7.Civ.CJ 'TOTAL: ELECTRIC PEE
O Lender's Name
F Leaders Address (7ry. MSCI IANICAL PERMIT FEE PLUMBING ITE
U 1 cmify that I have mail This application and shite that the above infomlmion is
M1Wi consul. to comply with all city antl county nrdinuncex and stmelaws relining to PERMIT ISSUANCE MECHANICAL FF:E
building construction,and hereby authorize representatives ofthis city menterup:mthe
U z abnve-mentioned property for inspection purposes. ALIHR OR ADD TO MECI I. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the Cory of Cupenina against
Ilab"'en.judgmerl cos sena expenses which may in any wiyaccnn,...asl said Cd, AIR I IANDLINO(NIT(TO 10,000 CPM)
ca eyuencco Eng of this 1.
AIR I(ANGLING UNIT(OVER 10,000 CFM)
I
re of ApplicanpContractnr are TDO AUSTHOOD(W/DUC t PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date as, #
Wi111he applicant or future building occupant store or handle hazardous..coal HEATING UNIT(OVER IW,00013'1'U7 A
as defined by the Cupertino Municipal Cube,Chapter9.12.and the I lealth and Safety
Code,Section 2553$a)1
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will the applicant or(atone bpilJin BOILER-COMP(THP OR 100,(100 BTU) ISSUANCE DATE
gby the Bay Are. mnmuality Management it 11Q� pp ryry
hoznrdous air comvminanls m defnea by @e Nay Area Air Quality hfanagemenl BOILER-COMP(OVER 100,000 BTU) y- A I Y
DivricR
❑Yes ❑No NEW RESIDENTIAL MECI,. SQ.FT. NOV V
1 have read doe hazardous materials requirements under Chapter 6.95 of the 1 9 '992
Celifomia I Icu10,&Safety Code,Sections 25505,25533 mW 25534. I undesstend the,
if the building does not currently have a tenon,that it is my responsibility to notify the
ecapam of the an ulrements which most Ito mel pater to i....act,of a CenlBwle of F rITY Ur CUYCn lI IHIv
Owner or aulhorimA agent Dale TOTAL: ISSUED BY:
OFFICE