24809 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO tl Rmusi;-EI.hC'GRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24809
BUILDING DIVISION BUILDING PROJECTIDENI'IFICATION
BUILDING ADDRESS: (jhh SANITARY NO. APPLICAtION SUBMffTAL DATE:
196.31 2 UNI'1'p OTb
OWNERS NA e0_PHONE: CO 1 7 ` N/C CONTROLb
RCHITECT/ENGINELR: LIC NO: F ❑
CONTACT PHONE: QTY. ELECTRIC PERMViVtA BUILDING PERMIT INFO
BLDG ELECT LU MECH
PERMI F ISSUANCE ❑ ❑
LICENSEDCON I censed under M'SDECLARATION APPLIANCES-RI?S IDENTIAL LOB DISC I ON
p02 Thereby of Divisior Bad on
3 ofd. Brain ,and rofesion,apter Could,
and
(commencing with
t+l O_O Senior a anti of Division 3 o(the Bminess and Professio.Code,and my license is in PANELS
mW fullforce and effect. C�
d�y� cru xs IJc.b �/ UPT02W AMPS
y< Date Contractor 201-1000AMPS
FDZ ARCHITECTS DECLARATION SQ.IT.FLOOR AREA S/SQ,FT.
ZOw— l understand my plans shall be used as public records. OVER IOW AMPS
OZ—LI
F h t W SIGNS ELECTRICAL
<y j Licensed Professional
W pc�< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
X060I hereby affirm that 1 oto exempt from the Cannons,License Law bathe
Wit+-vFi following mason.(Section'/031.5,Business and Professions Code:Any city or county TEMP.MSfER OR POLE INST.
1_a O< which requires a pvrit to xonswn,alter,improve,demolish,or repair any structure
�m'T� to its issuance,also requires the applicant for such rino file a signed sediment POWER DEVICES
prior 4ui pP a 8
pO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
u Xoi 9(coempacing with Section of Division 3 of the Business and Professions Cale) SWIMMING POOL ELELTkIC VALUATION
to—m orthathe isexempl Nerefromand Ncbaxisforthe allegedexereption.Anyviolation of
say Penni 1 applicant Penalty OUTLETS-SWITCI IES-FIXTURES
FZY to,n...701.5 by an applicant Permit then licanno%civil h f
senors than fire,hundred dollars($5001).
KONEW RI3SIDENTIN,F.LECIR _SQ.FT.
_o ❑ 1,asowncrofthepmperty,nrmyemployees withwagesestheirsnlccampensatinn, STORIES 'TYPE CONS'fRUCT10N
a3=° will do,he work,and the structure is not intended oroffcrel forsale(Sec.JO#a,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property who haild,mimprovez themna,and whodoc,mah work himself...Nrough his
ownemploycer,provided that such improvememsare not imcndedoruffertd forsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year ofcompletion,the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as ownerof thepropcny.um exdusivelycontracting wiNlkttueJ connamom in QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
conswct the prdorl(See.1614,Business and Professions Cade:)The Cantratemn
License Lawn—not applym anownerofproperty who builds mimprovesthertoq and PERMIT ISSUANCE /
who commtns lar such prnjoc¢wiihncantractnr(s)lioenxed pursunnOo,heContrnelxrte ALTER�DRAIN&VEN (CA)License Law. ) FEE SUMMARY
❑ I am exempt under Sec. .B&P C for this reason
BACK FLOW PRO"IECT.DEVICE O I:SIDE FEES
SANITARY YN
Owner Dam RECEIPT p
DRAINS-FLOOR.BLOW,AREA,COND.
WORKMAN COMPEcate ofIONDECLARATION r SCHOOL TA% Y N
[] Ihereby affnh,h lahave a st..prificarem(conxnuoof(See 38 o,a ceniate of RECEIPfp
Woken'Compenzation lnsurena nrucenified copy thereof(Sec.38W,Lab Cl)which FIXfU � C P L. PARK FEE YN
rsall employed,t la,fi is permit GAS-Ii2.SYS :M-I&C."4 S RECEIPT#
Policy b BUILDING DIVISION FEES
_ .
Cmil GAS- 1- 4 I PLANCHECK FTE
IMAQnified copy is hereby furbisher,
Certified copy in filcxl wish the city lrepection division. GREASFil .W IVVEgt2q q., GRADING FTSE
CERTIFICATE OF EXEMPTION FROM WORKERS' SETRAP SOILS FEE
COMPENSATION INSURANCE
(This%action need not be completed lithe permit i.Barone hundred dodars(SINA SEWER-SANITARY-STORMEA.200FT. ENERGY FEE
orlcss)
I cer if dal in the peraremnee cif the work far which this permit is issued.I shall WATER HGTER W/VENT/CLECTR
employ any person in any m% s o as to become subject ser the Waders' PAID
z Cnmpensmion Lawsof Califomia. DateWATER SYSTEMTREATING Date Receipt if
Applicant
zQ NOTICE TO APFMCANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL
rn become subject o the Workers Compensation provisions of the Labor Code,you must
? limhwas,comply with such provisions or Nis permit shal l be deemed revoked. BUILDING FEE
(] CONSTRUCTION LENDING AGENCY SEISMIC FEL'
lLUI hereby affirm that there is a construction lending agency for the performance of z the.work for which this peril is Model(Set,3091,Co.C.) ELECTRIC 1918
Iende/s Name
0 F Lmdcls Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I oenify,hat 1 have read This application and ,are that Ne above information is MECHANICAL FTE
>1 0. cmoct.Iagree to comply with all city and county ordinances and Stam laws relating,. PERMIT ISSUANCE
F" buildingor...,ruction.and hereby authorise repreumatives of this city to enter upon the CONSTRUC'HONTAX
U Z above-memione i property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify and keep harmless the City of Cupertino against
liabilities' ems.....send expenses which mayor any ovyneena,ngitiristsuid City AIR HANDLING UNIT(TO 10,000 CFM)
in c sof the ur of this ril.
AIR HANDLING UNIT(OVER 10,000CFM)
.ignaZe 91 Applicm,/Cnnracmr Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE LEAFING UNIT(TO 100,000 BTU) Date Radio#
Will the applicant or future building occupant%mre or handle hazardous material
as defined by the C.,rtiao Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cade.S,a,inn 25532(.)1
❑Yes ❑No VENTILATION PAN(SINOLIi RFSID) --
ISSUANCE DATE
Will ihcapplican,or future buildingaccupant useequipmemordevices which emit BOILER-COMP(31IPOR IW.W BTU)
haysrdoYs air orchninams as defined by,he Bay Are.Air Qual,y Management BOILER-COMP(OVER 100.000 BTU)
District? PAID
❑Yes ❑No N[W RESIDENTIAL MECH. SQ.FT.
1 have read the,harardom materials«,momarnts under Chap¢r 6.95 or the I]QAD - y
California Heald&Safe,,Code.Sections 25505,25533 and 25534.1 understand that 190eS
if the building does not currently have a mount than it is my responsibility to noti fy the 1 93
occupant of the requirements which must be met prior in issuance of a Certificate of (�
Occupancy. Cl/It
Owner or authov<d agent Date TOTAL: ISSUED BY: VI-
OFFICE