24781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-EI RICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24781
BUILDING DIVISION BUILDING PROJECT[BESTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
10 UNIT# LOT#
OWNERS NA ` PH E: CONTR(t OR'S NA �L ��L�r.� 7
/V J E J NIC CONTROL.
RCHITECI'/ENGINEER: LIC 'O: ADER'SS:
_ 7 C.3 *4. /Q✓e
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE ox BUILDING PERMIT INFO
BLDG 'LE PLUMB MECH
PERMIT ISSUANCE �� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p d'Z Iheom,affmAnd l am livenscdunderproviai of Clapmr9(comnnowing with /rte JOB DESCRIPTION
l000Sec,ion)WU)of Division 3of the dusinws and Professions Crate,and my license is in PANELS
W— ■ 1�_ tea .
r e and effect. /''
QL. rm.Class C'1� Lic.# 5776> UP TO 2W AMPS
ti y Dole 201-IOW AMPS
ZD�Z ARCHITECTS DECLARATION OVER I(NW AM1IPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z—0 I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licemed Professional
KyCQ OWNER-BUILDER DECLARATION SPECIAL CIRCIJUDMISC.
xC)W, I hereby aRmt that I am exempt from the Contactors License Law for the
W 3 a v, following reason.(Section 7031.5,Business and Professions Code:Any city memory TEMP.METER OR POLE INST.
which requires a permit m construct.alter,improve,demolish,ar repair any strumum
W} to its issuance,also re the applicant for such tto fileasi dstmement POWER DEVICES
prior quires pp pemti gee
,j<C, that he)s licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECJ�lvTRIC
o.ao� 9(romancrangwlm Sec1ion70Wgof Divi,om3ofmc Ba,hessand Pmfesslons Code) VALUATION
�^y milest he hce rrnpt therefrom aadthe bakfar,heallegedexemptimu Any violationof OUTLETS-SWI'1'CH[S-
FZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of FIXTURES
KFonot m1. town rofiheive rodny.larmf cep. NEW RESIDENTIALELECTR _SQ.FT. IFS TYPECONSTRUCTION
❑ Lasownerofuhe Property.ormycmployas with wagcsas theirsolecmmpcnsation.
US.3� will do the work,and the structure is not intended oroffard hoode(See 7014.Business
and Professions Coda The Contractor's License Law docs not apply to an owner of
pmpeny who builds orimproves former,andwhoacessuch work hursa forthrnghhis
monemployars,provided that such improvem,msarenot intendedoroffcred foraale.If, OCC.GROUP RCS UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
aalc). QTY. PLUMBING PERMIT FEC FLOODZONE AFN
❑ Lmown,rofthe prenoty. with Th Com...rshs
License no ewsnot(Sec.)044,❑uslnewi and Parosmia Codc:)The Conon,ana
Licenernmersmsnotapplytoawith ac afpropenywhrsedpuorimpto the thcrrnn,and PERMIT ISSUANCE
who contacts[m such projm¢with o mno-ecmr(s)Ilronxd pursuanvo me Contractor's
License Law. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Door DRAINS-Fl.00R,ROOFAREACONII. RECEIPT If
WORKMAN COMPENSATION D17CLARAI'ION , , SCHOOLIAX Y N
❑ I herebyaffirm that l have a cenificale efcomentto self-insure,oracenificaleofI§XTUR6S-PER'fRAP RECEIPT#
Workers'Comp mtiminsuanceoracenifiedcopythereof(Sec.38W.l.ab C.)which PARK FEE Y N
cover,'all employees under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy If BUILDING DIVISION ITIS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Ceniful copy is filed with the city inapatiun division. GRI:ASF/INDUSIRL WASTE INTERCIi1TOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS PEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forms,hundred dollars P5 100) SEWER-SANITARY-STORM EA.201 ENERGY PEE
or lass)
I cantly that in the p,rfnrmuuceurtheavi,farwbichmispersitisissucd,lshall WATER HEATER W/VENT/ELECIR
not employ in .'son
in any �kk m in become subject m the Workers' PAID
O z Co.— a Califs a'✓ae WATER SYSTEM(fHEATING De,o Receipt
O E
z OTICET PLIC T:If,also rah finis CeniSion of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r,o the Workers Compensation provisions of the Labor Code,you must
? onhwit reply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. Q
CONS'1'RUCI'ION LENDING AGENCY SEISMIC FEB
.7. z I hereby affmn thin he,,isa ena,maricn lcndingaganey forme performance of
U O the work for which this .it is lssaed(See.309),Civ.C.) TOTAL: F.LECIRIC FEE
1>0
Lenders Name
0 F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O U 1 certify thin 1 have read this application and state mat the above information is MECHANICAL FEE
�'^ W correct Iagree bt comply with all city and county ordinances and one laws return,to PERMIT ISSUANCE
F buildiagconsunctior,and hereby authorize representatives of this city to enterupon the CONS'I'RUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
- (Wt)agree to save,indemnify and keep harmless the City of Cup,nion...in,,
Indilities.judgmenu.cons anders,reses which may iomy wayinerm, gs imt said City AIR HANDLING UNIT(TO 10,000 CPM)
in cone tee of the graatisl ofmis pe R.
AIR HANDLING UNIT(OVER I0.11(III CPM)
44
Sign -AppllcanllCtn,mcrorkrI Da,4, V EXHAUST HOOD OVMUCT) PAIS)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Date Receipt#
Will,he applicm,or fuwrc building accupant mor or handle bvaolives maarial HEATING UNIT(OVER IW,000 BTU)
11Yea ❑No defined by rhe Cupertino Municipal Cade.Chapter 9.12,and me Health and Safety
Cede,Section 25532(.)) VENTILATION PAN(SINGLE RFSID) 1
❑
ISSUANCE DATE
Will me applicant or future buildingnccupaa,useequiperemmrdeviees which emit BOILER-COMP(31111 OR 100,000 B'I'U)
hazardous air nmamiman,as dcftned by the Bay Arca AG Quality Management BOILER-COMP(OVER 100.000 BTU)
Dionysus
❑Yes ❑No NEW RESIDENTIAL MF,CH. SQ.FT.
1 have read the hazardous mmcroo,requirements under Chapter 6.95 of me P A 1 p
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
ifthe building docs not currently have mention.that i,is my responsibility fortuity the ea
occupant of me requirements which must be met prior So issuance of a Cenifear,of FED FS//
Occupancy. /s
Owner or authorized.gem, Date TOTAL: ISSUED BI!
OFFICE