24631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' .G- LE RICA], PERM[ NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24631 sM„erre?:"tit BUILDING PROJECT IDENTIFICATION- ';P L
BUILD IN'G ADDRESS:
(^ SANI'1'AR1'NO, APPLICATION SUBMIT]AAL UA'D?
• < 1333 \T UNIT* LOT IZI�'/
IW'NEP�iRSNAME: PHONE: CONTRACTOR'S NAME: LIC NO: L V
r N/C CONTROL#
ARCHITECI'/E'.F'il�:•:R LIC NO: ADDRESS: ❑
Y.
ll-
CONTAC1fn�n I-(1 rPIIONE: ../f QTYe'r(y�Ll ELECTRIC PERMIT sau 'Xea�)a +C'FEE d ' � .`BUILDING PERMIT INFO i.'.=^x
6ao s+_ � �7 2-1 7 � 1 Y RA TISSUANCE •a6 H i ;o• * r) BLUG ELELT LUMR MLCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hcmbyaffirm that l am licensed under i faa t 9(commencin with 108 DESCRIPTION
]5Z prdp Peso Pere ei
700 Smtion]OW)of Dtvii tithe Business and Professions Code.and my license is in PANELS (,
yU5 Lull icense hensand ect. Y ` ./rte
_ZW License Class Lic.p UP TO 2W AMPS
q<y Dare Contractor 201-I"AMPS
-r�reor RCIIITECI-S DEC ATON OVER I(IOO AMPS SU I'f.F1.00R AREA b/SQ.FT.
N z I understand my plans shall be used as public records.
F m SIGNS ELECTRICAL
jLicensed professional
PizQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Jim 1 hereby teff that 1 am exempt from the Contractor's License Law for the
_Orn fallowing rcaun.Section 7031.5.Business and professions CodT,
Cradle:Any city or county TEMP.METER OR POLE INS
x h,,b requires a permit m consruct,after,improve,demolish,m repair any etrucmre �
!!}2 one its issuance,also requires the applicant for such permit to file a signed statement IPOW 2JICES° „
Y�0 that he is licensed pursuant to the provisimts of the Contractor's License Law(Chapter _
_=z 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC - 1 VALUATION
a or that he is exempt therefrom and to,basis for the alleged exemption.Any violaeomof
T Section 7031.5 by anytiliplicant fora t ubats the applicant toe civil penalty of OUTL�fS-SWITCHES-FIXTURES
-z6 t moa than five hundred dollars($500).t s )
=? n❑ Lasawncrofthc n .oro to aswithwa csastheirsole cote iwnion. NEW RESIDENTIAL[LECIR STORIES TYPECONSTRUCTION
Toa Y YcinP Y f P<
r3' will do the work.and the structure isnot intended oroffered Pomle(Sea.]6la,Business
ane Professions code:The Commnmr's License W w does mot apply to an owner of
pmpemwhobuildsorimprovesthemon,wdwhod«ssachworkhimu8orW ughhis
wn etnployms,provided thin sac h improvements me not late ndcd or offered Por.ic.I L
OCC.GROUP RIS.UNITS
however,the building or improvement is sold within one year o(completion.the owner. TOTAL'
diilder will have Or burden of proving than he did rat build or improve Imf Parise.of -
sa1cJ. u_
"e”'
s a Se..
QTY arW "}4SQ NPUUMHWG PERMITt x;fr ' FEE xr� ; FLOOD ZONE APN
❑ I, rofthe limpet , m
aexclusivelyconmcting with licensed connano t M,-rent *1 wyAy.••.s-,pa aa•^:ac.vi:,v ;sµe�a.
consumer thenpoject(Sec,7614.Business and professions Code:)The Contractor's PERMIT ISSUANCE
License Lswdmaa not apply to sonowneroftimpsmy whomildsorimproves thereon,and
License
wheLa<ts fm such pmlects wieuconvactor(sl(leen.n pursuanuo the Contramor's - _. . .
u Isco. ALTER-DRAIN&VENT-WATER(EA) `i)2 -'r`jtiW}f" ,) FEE SUMMARYr��G.u. ~%;I:'.Y
❑ 1 am exempt under Sm. ,R&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
•�Owner Data RECEBT#
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
by affirm that I have a certificate of comm to self-interum,or a ceni8cam of RECEIIT a
.i �Rcorkers Compensationlnsumnce oracenifW copy ihveof(Sec.3g00.Leb C.)which FIXTURES-PER TRAP - PARK FEE' YN
•ire+ covers all employsis under Of,permit/ GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
r Policy# BUILDING DIVISION FEES
Compact, 'I�1e GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Candied co k lic,ebyfumishcd.
�Cenified copy is filed with the city inspcceon division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the prim is forma,hundred dollars(Sl 00) SEWF,R- ANITARY-STORM EA.200FT. l� ENERGY IEE
or Tess.)
I cent,that in d¢performenee of the work for which this .if is issued,i shall 4af6 HEATER W/VENT/ELECIR
not employ any person in any m as to became ,abject to the Workers' PAID
Cmn'souionlawsof Califmmia. Dec so WATER SYSTEM/TRFATING Dec Ramipt#
Z' Application
2 NOTICE TO APPLICANT:If.after making this CenlOcam of Exemption,you should NEW RESIDENTIAL PLM,. SQ.Ff. TOTAL:
y bcemme subj«t to the Worker's Compensation provisions ofthe Labm Code,you must
BUILDING FEE
= � forthwith comply with such povisions or this permit shall be domed invoked. Sr
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ih by fromthe It .wamn lending'ane,for the perfonnur f
ZQ thew k fN h th s pe t d(Sec 109] C s C) I ELECTRIC FEE
Londe s Name— p[pLJ v-Z, e � �• -- s++ F C•i' PLUMBING FEE
F Lend AJJ / QTY ",;)� MECfll PERMIT-+' fy FEE
U ei .P
L'] I certify etm 1 have«it this applicationu and snag that the shove laws
en . MECHANICAL FTSE
menet.IaFatocompld withall cifrcri muntyntainanttsand nate enter
gm PERMIT ISSUANCE
Z trearenmentiomctiomandhercbv rinspection ereiroes, fives nfthiscity to enter upon the CONSTRUCTION TAX
) 'Z above-mentionedp save, nd inspection rid purposes. ALI}R OR ADD TO MECI I.
(We)agree nt save,indemnify and keep harmless the City of an{on againstliabilities,judgments.cosh and expenses which may in any way accruea agagainn said City AIR HANDLING UNIT(TO 10.(100 CFN11
in e9y�yyenee of th granting mf this permit.
`� /��}�'-# /��f-f AIR HANDLING UNIT(OVER IO.OW CFM)
SgnmureofApprcanJf�or Da. XIIAUSTHOOD IWDUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0X0 BTU) Doe Receipt#
Will the applicant or future building occupant atom or handle hazardous material HFATIRG U@IT(OVER 100.000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealm and Safety
Code.Section• ^_55320)?`g",. VENTILATION FAN(SINGLE RESID)❑Yes �'' ISSUANCE DATE
will thea (neem or fumrc huildln necu Luse mrJnices whichemit BOILfsR-COMP(IHP OR IW.W(1 BTU)
Pp 6 Pan rquipmen _ .
harardi air a norma deed by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) Y
.District? �s[)
f
>
11 Y" CINo NEW RESIDENTIAL MECH. SQ.FT.
1 have read the la—mous ma trials requirements under Chapter 495 of the
Glifmnla Heahh i Safety CW,Sections 25505.25533 and 25534. 1 understand that V s.
if the building docs not curemiv have a term,that it is my responsibility s,notify the _
ne<upem luucmcnrc wh/ich/rymy h met poor to issuance of a Cenifca¢of
Dec TOTAL: ISSUED BY:
OFFICE