24601 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1II.DIN .- .LF. RI AL. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. n /I 4 oCO
BUILDING DIVISION BUILDING PHOJEC-I'IDENTIFICATION G
BUI INGAII RESS: /J SANITARY NQ APPLICA'I'IONSUBMITI'ALDATE
VI
W UNIT# LOT# �yl`VGA7
O ERS AM` O CO R' N M
N/C CONTROL#
ARCHI'MC171INGINM : LIC NO: A ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MIiC
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
cwz Ihemby off.that l am licensed underprovisionsof Chepmr9(ctummencing with -
FyFO�VVZy pLEUEW1 n7tx0)o dm
Jwd afessi ads,anmylicense is/inPANELS
fall
frmA t. UPT02%AMPSLicense
CaptHDy Dar Conwnnr 301-10110AMPS
ZOyZ ARCHITECPSDE OVER I"AMPS
SQ.FT.FLOOR AREA S/SQ.PI'.
I ts^dem d my plain shall bo used os publi<rttords.
Licensed Professional
SLECIBICAL
a OWNN.R-HUILDIiN DECLARATION SPECIAL CIRCUIT/MISC.
� LED IN
XOaF 1 herby affirm that I am exempt from the Cotnrcw/s License Law for the
m3Oy4 following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE:INST. t 1 g
�0J which requires a permit r construct,alter,improve,demolish,or repair any structure U
L �7 prior to its isem^ce,atso requires the applicam for such permit to file a signed statement POWER DEVICES
TER
mp0 thin he is l lcensedpursumn intbe provisionsOrion Commonr'x License Law(Chapter
p� 9(commencing with Second Xg%)of Division 3 ofthe eminess and Professions Code) SWIMMING POOL ELECTRIC ATION
2, or that he is exempt therefrom and the basis for live alleged exemption.Any violnionof OUTLETS-SWITCHES-Il%TURFS
tZQ Section 7031.5 by any applicant for a permit subjects the applicant an a civil Penalty of
O
not mor than Five hundred dollars($500d. on, NEWRESIDENTIALELECTR _SQ.PT.
p ❑ Lmnwne.dlhcnsp.e,.m Imyempindewwithwed forme(Ser.nsmpcnsiness STGRIIig TYPE:CONSTRUCTION
willand dothewonsCde: he Contract.is Licensed e
doss.apply 7044.Business
of
and cay,Professions Code:The Contractor's nd who Law does not apply lf rt owner is
oroemloyms, ovid mprovcsthcmpmvmctsmmtimm�doess such koroffe arfr e.If, OCC.GROUP RES.UNITS
however,the es,provided improvement
ewof ompleertd the moe.If,
however,the building ofde no verve^n is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not buil)nr improve for purpose of
ala).
❑ I,ns^wnerof the prmpeny,am exclusively contacting with licensed conwctorsm QTY. PLUMBING PERMIT EEE FLOOD ZONE APN
omit.the project(Sec.7014,Business and Professions Code:)The Contractor's
License Lawdoesnot apply loan owner Mprolamy who builds or improvesthemon,and PERMIT ISSUANCE
who contracts forsuchprojects with a comrmtor(s)licensed forward lathe Contractor's ALTER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE oMIDE F1,17
SANITARY Y N
Owner Dor RECEIPT#
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
❑ Ihcmhy affirm thatlhuvc acenifcar of consenno self-imure,o scarp Ecate of RECEIPTp
MIXTURES-PER TRAP
Workers'Compensationlnsnrunce orucenifed ca there�'(Sec.3g00..nM1 C.lwhich PARK IZL> YN
covers ell cmplon's'Tt=tlaLt1)isvefiiQ7 — GAS-EA.SYSTEM-)INC.4OUTLETS ultrr,14p
Pmlicya C l(a�(ir BUILDING DIVISION MES
Company GAS-EA.SYSTEM-OVER 4(fA) PLANCHECK FEIi
❑ Cc and copy,is
oiled copy is flleJ wit the clry imleaion division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action random be completed Ellie permit is fortune hundred dollum(SIM) SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
or less.)
I certify that in the pperfommawc of the work for which this permit is issued,l shall WATER HEAT ER WNF.NTf?I.ECTR
nut employ any person in any mower in,m to become subject to the Workers' PAID
z CmopmwumdLwvstuf Culifnmia.' Data WATER SYSTEMG"REATING Date Receipt#
Applicant
Q 0 NOTICE TO APPLICANT,If,offer making this Cenifcate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
In become subject to the Worker's Compensation provisions of the Labor Code.you must
� , forthwith comply with such provatemnr this permit shall bedemednavok.l. BUILDING FEE
yo CONST RUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
V O the work for which this permit is issued(Sec.3007,Civ.CJ
IY Lender's Name a PLUMBING FEE
O �'! Lenders Address QTY. MECHANICAL PLRMIT FEE
lJ I certify that 1 have rad this applicatiw and sum that the above information is a�
OW.. cornacI to lacomply with all<iry anJ coumy ordiwnccs end slate laws rtlming to PERMIT ISSUANCE MECHANICAL FEE
F' buildingcon ry imply Ne CONSTRUCTION TAX
(� above-men nn< p ray for inspection purposes. ALTER OR ADD TO MECH.
(We) till, .e,indemnify and keep harmless the City of Cu Wino a elms.
liabilities, t osiswd expenses which mayor any wayaccmea 'ins.su City AIR HANDLING UNIT(TO 10000 CFM)
in conseynce e ting of it.
�q I A, AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ppbrarV nm amore Dme EXHAUST 1400D(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1o0,Ow B'TU) Dam Receipt#
Will the applicant or future building=opal start or handle hauardous material HEATING UNIT(OVER 100.0008711) TOTAL: s�
as defined by the Canadian Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section 25532(a)?
❑Yes ❑No VENTILATION FAN(SINGLE REBID)
Will thenpplicwmrfummbuildingccu
opunt useeqmemouiprdevic<swhicb emit
HOILER-COMP(3HP OR HIQIXO BTU) ISSUANCE DATE
•
hazardous
air contaminants w;defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,1100 BTU) fs p Q
DinricO
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,PT.
1 have read the humrdous materials acquirements under Chapter 6.95 of the DEC 15 199
California Health&Safety Care,Sections 25505,25533 and tw
25534. 1 underad that
if the building arcs not carnality have a mount.that it is my rspomibility la wtify the
cupant of the requirements which mast he met prior to issuance of a Certificate of C
Occupancy, CII I %Q L /r
Owner or mflorimd agent Date TOTAL: ISSUED BY:
OFFICE