24451APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOII(II,DING - DLDCI'RICAL
APPLICATION/PERMIT PLUM NG - MECHANICAL.
BUILDING DIVISION BUILDING PROJECT SHEN'1'IF-ICAI
PERMIT NO.
/I p4 J 1 C q
24'ION
BUILDING ADDRESS:
SANITARY NO.
APPLICATI�ONSU/B�M�fW,,
LIO lJI'If� OIL�J�G11�{ UNIT LOT
1TALDA
O RS NAME: PHONE:
CON_TRACfOR'S NAME: LIC NO:
N/C
❑
CON'I'ROLa
q
I•
Z� ZLZ17C
I
AR ITECT/ENG F.F LI NO:
L
ADDRESS:
�O�l
CONTACT: PHONE:
QTY. ELECTRIC FERMI FEE
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
IS �^
I) I% s` _
LICENSED CONTRACTOR'S DECLARATION
Ihemhy uffimttbullanlicenred unJcrprovisina.nfChapter9 (rommeneing with
OAPPLIANCES-RESIDENTIAL�pplus�
/�LTY7
PANELS
Section7kx))of Division Sof the Businessland Pride,wions Cudc,wd my license is in
full force and effect.
License Class Licp
UP T0200 AMPS 0
SI
201 - 1000 AM .
Dae Co uncen
S . T -,A $/S . FT.
M U T E
ARCHITECTS DECLARATION
cu
undcextaM my plans shall be used as public records.
VER ( A S
NSI. ICAL
hicen.rcJ 1'nUessionul
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Commit Li -.'a Luw for th
S I .CIRCUIT/MISC.
TE
TEMP. METER ORP .I
Pollowing reasov.(Scctiun]03L5, 9usinar and Prnfeksinns Cmlc: Any city or county
which requites a permit to consuum, altar, improve, demolish, or repair any slrucmre
prior to its iscuwre, alsorequims the applicant for such permit o file a signed smwmenl
POWER IC'
that he is licensed punuwl m the provisions uRhe Commctor's License Law (CTafter
9(comommag with Section 7000) of Division 3 of the Business and Profeusiens Code)
err that heisexcmpuhercfrom and the basis for thealleged exemption.Anyviolalion of
Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
SWIM IN O
I, ELL IC
///��� VALUATI[Ibe_
y`IC�Y
,I.pLE '- TC -FIXTURES
nut mom than Bvc hundred doll... ($500).
❑ Lasowneroftbc progeny, ormyrmployces with vagesastheirselecompemalion.
NEWRESIDE' IALELECI'R SQ.FT.
STORIES
'TYPE CONSTRUCTION
will du Neva rk,and the structure is not intendedoeo(fered for sale (Sec. 7044. Business
and Professions Code: The Co nnieforx License Law does not apply to an owner of
property wlmbaildserr improvs thereon,and whodoessuch work himselfonhrough his
emplayeeapmvided tool such improvcmenlsarcnol mendedoreffcad forsdc.If,
OCC. GROUP
TS
however, the baildingor improvement is sold within one year of rompletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
-
nprnfth exduss comrauingwith nactorsm
FLOOD ZDNE
,
EA
(Sea. 704,L an de:) The Contractor's
Business and is ho bons Code:) The Comon.and
�ric the project (Sec. owner or
�����I//6rr111"`... eLawdcesnolapMects
PERMI'I'ISSUANCE
with acofpropenywhosed Pursds
uant to thel Contractor's
Lwho iecow lractsforsuch projects withaComracror(.)licensed pursuant to the Commaor's
Liccnse 1„l..
ALTER DRAIN&VENT-WATER (IA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEL
SANITARY YY
NT:CEIPI'p
Owner DateDRAINS-FLOOR,
ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihemhy affirm that l have acenificum ofeon¢m mself-insure,ora cenificaleof
Workers' Compensation lnmmnreor. renifed Copy In..00f(Ser. 3800, Lab C.) which
coven ell employee's under this permit.
Policy a
RECEIPT If
FIXTURES-PERTRAP
PARK FEE Y - N
RHCEIPT p
GAS -ICA. SYSTEM -1 INC. 4 OUTLfa'S
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE.;
❑ Cenificd copy is herehy fumisord.
GREASIVINDUSTRL WASTE INTERCEPTOR
GRADING FEL
❑ Cenificd copy is filod with the city inspection division.
CERTTI PICA'1'li 0I7 EXFMP1 ION FROM WORKERS
GREASE "TRAP
SOILS PICK
COMPENSATION INSURANCE
SEWER-SANITARY-STORMEA.200FT.
ENERGY FEE
(This sawairromarl am becompleml ifthe permit is(crone hundred dollars($ 100)
less.)
WA'F'ER HEATER W/VF,NT ELECTR
Icerlify0mtin She performance oftbe work forwhich Shispennitis kited, l shall
not employ any person in any manure sou to become subject to the Workers'
PAID
WATER SYSTEM/TREATING
Compermationlvwsof Califoml.. Data
Date R pl
Applicant
NOTICE TO APPLICANT:It. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PI,MB. SQ. FT.
TOTAL:
become subject o the Worker'x Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall t<damed resolved.gU1LDING
FLT: -0—
rCONSTRUCTION
SEISMIC FEE ,
CONSTRUCTIONLENDING AGENCY
I hereby of cal that them is a construction lending agency for the Performance of
She work for which this permit is issued (Sec. 3097, Civ. C.)
Leader's Namer
TOTAL:
ELF.CTItI F:E
QTY. MECHANICAL PERMIT FEE
PLUMBI F ^�
Lenders Address
1 certify that 1 have read this applicaion and stem Shat She above information is
rtem. lagrce So comply with all city and courtly nrdinwces wdsmSe laws relatingto
PERMIT ISSUANCE
MEC A CAI. FTi
building wnsnuction. and hereby authurim representatives ofthie city menmr upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MI CH.
COISIRUC 11ONAS
(We) agree to save, indemnify and kap harm) ss the City of Cupertino against
liabililies,jud . mstsan x eswhich w�ymaClSy
n
AIR HANDLING UNIT Tf010,000 CFM)
AIR HANDLING UNIT (OVER I0.000 CFM)
in com. t gran' .mit
EXHAUST HOOD(W/DUCO
PAID
Si a ter Date
HEATING UNIT (TO 100,0011 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam R«eipt a
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Willthe applicant or firm. building area,rtstore or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
ISSUA 'CE UIA7E Ica`
Cod, Section 25532(a)?
❑ Yes ❑ No
BOILER- COMP(3HPOR100.000111'U)
Will thea licwmr(uturcbaildin fusee mrdeviccswhichemit
pp g«capon ympmen
BOILER - COMP (OV It 100.000 BTU) '
haurdous aur contaminants av refined by She Bay Arta Air Quality Management
.Oistrict?
NEW RESIDENTIAL MFCII. SQ. IT.
❑ Yes ❑ No
1 have read the hazardous materials "trio me us under Chapter 6.95 of the
34. 1 understand
California Health & Safety Code. Sections 25505,25533 and 255Sha
p$ p M D
P
if SM1e holding doer not currently have o mown rho, it is my responsibility m ratify She
occupant of the requirements which must be met prior to Issuance of a Certificate of
ccupancy.
ISSUED BY:
Fr-
Owner«uutburimd a gent Dale
T(
OFFICE V11 yr J1UrcnIiDU