24598 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
(,TTY OF CL PERTINO 11 ILD!W:-ELECTRICA I- PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECxpNICAI. 2 4 5 9 8
IIUIhDING PROJRCT IIIE.NI'IPIC'A'1'ION
IUIL
6V RW `-W /V ` C UNIT LOTp SANITARY NO. APPLICATION SUBMITTALA1DAT
11-II-0-RIO
OWNER. AME: PHONE,: Cp�1'RACfOR'SNAM1 LIC NO:
LYN 5• P�CTf^- ate, �-r[\ NIC CONTROI,N
RCIII'IT:CI'/ENGINEHR: `C LIC NO: AaDD`B�-1FS,5: IV GJ�7 s ❑ ��
sJ
CONTACT: PHONE:
�p��6 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
O G BLD SLE PLUMB MEC!
PERMIT ISSIIANCF. /
LICENSED CONTRACT'OR'S DECLARA'ION APPLIANCES-RESIDENTIAL BDESCRIYf10N
CZ Ihercbyaffiblt that lam licemcdunderprovisiovnfCNpter 9(commencing with
00 Section](andefDivision 3af iheBminees and Professions Cali ylicensa is in UPTO AMI'# �u�e��
c UW mu forte and arc«t ��, •
�ZW Licenu Class _Lic.p 1 gT�K' �
Qy Dme.Lti14f�1�Contrmmr � >� 201-IWO AMPS
ZOn Z' x lltans mow`# __ A-��C""IIITECTS DECLARATION OVER IfpII AMT'S SQ.FI'.FLOOR AREA E/SQ.1,1.
0z_ 1 umlemanJ my plans shell be used ex public recoNs.
W SIGNS ELECTRICAL
N LiccnenlProleaslnnal
2,45W
y�d'Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xE�(IiU 1 hereby amrm that 1 nm exempt from Ne Conaumra License law for the
' ss1B Wti following reason.(Sortie.]031.5,Business and Profession,Code:Any city or money TEMP.METER OR POLE INST.
fS�� which reynires a pe.it to emobarL cher.improve.demolish,.,repair mty samcmm
ad to its issuance,also reforms the applicant forsuch uo Me a signednarnncnt
POWER DEVICES
Q prior DIA PP Ipmti
R' p that he is licensed pu,uan,to the Provisions of the Cuntranors Licenu Law(Clumetc
L p,o[L 9cammencin ) SWIMMING POOL ELECTRIC
% LL. ( gwim Section Division of me Business and Professions Code) VALUATION"
omhat he is exempuberefrom and the basin for Neallcged exemption.Anyviolatien ofOUTLCTS-SWITCHES J'IXTURI?S �)Oc_�
[-ZQ Section 7031.5 by any applicant for a Permit subjects the applicant toacivil penahyof YDV�1
C not..carbon five hundred dollars($500).
CA .
m ❑ I,usownerufmcproperty,ormyemployeeswish wvgesastheifsolecomNEW RESIDW IAL ELECOR 5 FT.permulinn, Q STORIES TYPE CONSTRUCTION
a willd,the wnrk.mrd the swaturcisnot incendedoro(fend forule(Sm.]044,Bus
and Professions Cede:The CommG.ses License Low does not apply to an owner,of
property who builds.r improves thereon.rand who dabs such work himsel f or through his
own employees,providedthat suchimprovementsamour intendedor.wooed fors ale.owner.
OCC.GROUP RL+S.UNITS
hawserw the ave t e burden of tarn g thin he di inond t build or comm a for m,poseof �•
builder will have the burden of rhes he did not build or int for f 3
proving prove puryrruo
❑ I,mowner of mepropeny,em reclusively connecting with licensed antmnn,m QI'Y. PLUMBING PERMIT FEE FLOOD ZONI? APN
consumer the project(Sec.7044,Business and Professions Code:)The Comracroes PERMIT ISSUANCE
License Law does ern apply m an......f mnitcny who build,a,improves thereon,hern,and
who contracts forsuch projects with a contractions)licensed pursuant to Commcmrx ALTER-DRAIN&VENT-WA'T'ER EA t,
License Lew. 1 ) FEL SUMMARY
❑ I am exempt under Sec. ,B&P C for this rcauo BACK FLOW PROTECT.DEVICE SANITARY OM I Y DPN
Owner Dam DRAINS-FLOORROOPAREA, RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby affirm that l have a ceriRcme ofeinunuo self-insure,or v certificate of FIXTURES-Flirt TRAP RECEU`P#
Workerx CompensationlnsuruneeoramrdfiedcoP there.f(Sec.3Bon,l.ab CJwliich PARK 1'BE Y N
coversall employee's under this Permit. GAS-EA.SYSMM-1 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTI?M-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby Published. (2 t!rA197
❑ Cenilied copy is filed with the city inspection division. GRPASFINDUSTRL WASTE INTERCEPTOR GRADING MH
CERTIFICATE,OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(IN,RedemaaAam beeompleted ifthe permit is for one handratmilms(Elmo) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I ani fy that in the Perforate.of the work for which this pemtit is issued,Ishull WATER HEATER WJVCNT/ELECTR
not employ any pennon in any member so as to become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTF:M/1REATING Date Receipt#
O 7-+ Applicant -
z NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIi. SQ.IT. 'OTAL:
r VJ become subject o the Workers Compensation provisions ofthe Labor Gide,you must
(Y forthwith comply with such provisions.,,his pemrit shall be deemed revoked. BUILDING ME sq
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEB.
,Z Iherebyafrmr that mere is aconsuuction lending agency for the performance of
the work for which this Permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FeskX 1q si,
Lcoders N. PLUM 1
0 U Lenders Address QTY. MECIIANICALPERMIT FEE
I certify that 1 have need this application end state that the above information is
acorrect. I agree to comply with all city and county ordinances and state laws relating to r PERMI'TISSUANCE / NI LFEE
U) building construction,and hereby authorine mptenenratives of this ckym enteruon pthe TR ION TAX
T, Z above-mentioned progeny for inspection purposes. ALTHRORADDTOMECH.
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
lin iries.judgmems,costs undespenus which may in any way mcraengainsl nniA Ciry AIR HANDLING UNIT(9'010,00,CPM)
inc al nc of me gmntin6 of Nis ryamit.
AIR HANDLING UNIT(OVER 10,000 CFM)
�f
Signewm of App¢anVContmdor Oma EXHAUST HOOU(W/DUCT) PAID .
HAZARDOUS MAT17RIALS DISCLOSURE HEATING UNIT(TO IW,"BT U) Date 6P.#
Will the applicant or future building occupant store or handle hainnious material HEATING UNIT(OVER IW,UpO BTU) f
u defined by the Capcnino Municipal Code.Chapter 9.12,end the Ilcatlh and Safety
Code,Section 25532(e)?
11 Yea ❑ No VENTILATION PAN(SINGLE RFSID) t
Will thenpplicant orfmure buildingacupam uuequipmrnmrdevicu whiehemit
BOILER-COMP(3HP OR Ifp,(100 BTU) ISSUANCE ATE
hatardeue air contaminants m defined by the Bay Area Air Quality Management
Distrim'I BOILER-COMP(OVER 100,01i BTU) p
W B
❑Yrs 0 N NEW RFSIDF.NTIAL MECH. SQ,FT.
1 hove read the hamrilm.am clan,oximaenten,under Chapter 6.95 of the CC 0 ��
California Ilenhh&Safety Code,Sections 25505,25533 and 25534. 1 unde,mnJ that p
ifthe building does not currently have a recent,thatit is my responsibility to notify the C S
acupvm of the rcyuiremems which must be met prim m issuance of a Certificxm.f /`r VP
Occupancy. QV/'Cfl/rV
(Twner or amhodeeJ engem Data ISSUED BY:
OFFICE