24641 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINOI. .-FUEL DUCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL 246
yl BUILDING PROJECTIDENTIFICATTDN
41
BUILDING ADDRESS, �i 1420 oe1-90 SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT it 12�
OWN NAME Q� r PHONE: C R'SN ME: LIC NO:
pCpR (^ t N/C CONTROL#
CHITECI'/ENGI'FIiR: LIC NO:
CONTACf: !S PHONE. QTY.
t BUILDING PERMIT INFO
. QTY. ELECTRIC PLRMI'f FEE
BLDG ELECT PLU
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p y�z Ihembyaffirm that lam licenud underprovisionsafCTapter9(commencing with JOB DESCRJON
$400 Section 7090)af Division Sof the Business and Professiam Code.and my license is in PANELS
q z full farce and effect. �T
Q License Class Lic.# UPT02MAMH
N y Dam Cnnvacmr 201-I"AMPS SQ.FT.FLOOR AREA S/gQ.FT.
I"m'Z ARCHITTiCT`S DECLARATION OVER 1000 AMPS
70m—
[understand m ka shall beusedas blit Kcmd.
Oy tills al t pa SIGNS ELEMRIC l,
CNa_ J J
Licrnud Pnefessional
AEU OWNER a.crom Ffrom DECLARATION SPECIAL CIRCUIT/MISC.
FXOyF. I hereby affirm that I um exempt from Ne Grmmdmo License law bertha
W3Y-r~il following reason.(Section 1031.5,Business and Professions Code:My city or county TEMP.METER OR POLE INST.
� which requires a permit m canatmcl,ober,improve,demolish.or rtparr soy 61NCNm
`dVtM Puerto its issuance.also reyuines the applicant for such Femur to file a signed statement POWER DEVICES
µ�j �sl that he is licensed pursuenl to the provisiomofthe Cmarm,or'a License Law(Chapter
dXp 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELEC9'RIC A VALUATTDN
yl r^y or that he is exempttherefrom and the basis for the alleged exemption.Any violation of UTI EL'S-SWITCIIES-PIXTURF.S
,Za Section 0031.5 by any applicant for a permit subjects the applicant a civil penalty of VVV ��FA/
p not marc than five hundred dollars(55110). NEW RFSIDFI4'DAL ELECTR 5 .IT.
41 p ❑ 1,usowneroflhepm ny,ormyemplo mswithwMesaslheirsolemmpcnution. Q STORIES '1'YPF.CONSTRUCTION
L willdo rhewmk,and the structure isnot intended oroffemJ formu(Sec.7(4,1,Business
and Profession Gmc:The Common,'a License Law does nm apply to an owner of
property wlmhuild,mimprovestherean,andwhodas such work himalforthmughhis
own employees,provideul that such improvememsam not imandcdoraffeared forsale.If.
OCC.GROUP RBS.UNITS
however,the building or improvement is sold within one year ofcomplelion,the owner KI
-
builder will have she burden of proving that he did not build or improve for purpose of
is
QTY. PLUMBING PERMIT AP
❑ Lm ownerofthe propSee.TO conexclusivelyand contractingwithC dc:)sedTh contractors
License
el the project(Sea.1044, per.fsa and ywholaons code)The Canuactars \V/Ifl IVy
License Law dmanot applYra rnownerofpropedy who M1uilJs orimprovm Nemon,ud I'F.RMI'f ISSIIANCP.
who convects forsuch pmts with acontNcmr(s)licensed purst uuo the Contractors
License law. I ALTER-DRAIN&VENT-WATER(PA) y
❑ 1 am exempt under Sa. .B&P C for this mason BACK FLOW PROTECT.1)'VICE
_ SANITARY YN_
Owner Date RECEIPT#
COND
AREA,, .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL TAX YN
Cl IheKbyafGrm that l have aanificateofconenno self-insuK,ors anifcate of FIXTURES-PER TRAP RECEIPI'p
Workers'Compensation Insurance or a cerpfied copy Nerwf(SCC.3gW,1ah CJ which �# PARKFBE Y N
Policy#1c{npt ye4s upd�luCpRmil,# / RECEIPTp
/911fY SC JV Tf '] GAS-EA.SYSTEM-TING.4(EA) TS BUILDING DIVISION FEES
Qrmp ei GAS-G.SYSTEM-OVER 41FA) PLANCl1ECK FET?
❑ CCtrifiedrnpy is heubyth fished.
CenifieJ copy is filed with the city inspection division. GRIiASFJINDUSTRI-WASTE fNTTRCEPI'OR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectionneedut becamplemd iflheperrnil is formolumdrMdollars(SIDO) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
or less.)
I codify that in the performance ofthc work for which Nis Permit is issued,I shall WATER HEATHB W/VENT?:LECIR
nor employ any person in any manner ser as to Income subject to the Workers' PAID
Compensmionl.awsof Culifmnia. Dam WATER SYSTEM/IREATING Dam Receipt#
O Z Applicant
Z�+ C NOTICE!TO APPLICANT:If.after making this Certificate of Rsemprion,you should NEW RESIDENTIAL PLMB. SQ.Pf. TOTAL:
CIJbecome subject..he Worker'sCcon,madon provisionofthe labor Code.you maxi �q
� ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEC Via#
CONSTRUCTION LENDING AGENCY SEISM IC ME
Z E hereby affirm that there is a construction tenth ng agency for the performance of ELECTRIC FEE
U O the work for which his permit is issued(Sec.3091,Civ.C.) 2 v
Lenders Name
ULender Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I comfy thor I have read this application and store that Ne above information is MECHANICAL FEF.
te m
correct.l agree to comply with all city unit county ordinances and smlaws mixing PERMIT ISSUANCE ��
E" buildiagconslruclion and hereby authorize mapresenrativesof thiscity toeaterupouhe CONSTRUCTION TAX
Vnyfor inspection puryosn. ALTER OR ADD TO MECI I.
u
rive-or agree to s indemnify and ked sonless the Cit of Cupertino against �_
liabilities,judgmenls.'o Pcw ayia.yw occru Baine xeid Cly AIR HANDLING UNIT(TO 10,"CFM)
i contrancee n go is,
s peI. I/701a
AIR HANDLING UNIT(OVER 10,0011 CPM)
Sign mmof Applicant/Comm r Dne EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0fit BTU) Date Receipt#
Will rhe mplicaat or falure building occupanntore or handle hazardous material
HEATING (OVER 1 W,IkNI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(u)? FAN(SINGER RfS10)
❑Yes ❑No
ISS NCE DATE
Will Ne applicanrorfmumbuildingoccupanruueyuipmemofdeviceswhichemit (311POR IOO,INq BTU) pp�# pp q
hyardous air conumimwnts as defined by the Bay Area Air Quality Management (OVER 100,000 BTU) P A V
Atn't?
J ❑Yes ❑No IAL MECH.—SQ.FT.
1 have read the hazardous mamrial6 reyuimmend under Chapter 6.95 of the ®EC 28 1992
Celifomia HeaOM1&Safety Code.Sections 25505.25533 and 25534.1 understand That
if the building docs nor currently have a tenant that it is my responsibility to notify the off
occupant of the reyuiremenb which must beat prier to i...mme of.Cedificate of M Ur LUre t y
Occupuncy.
Owner or mdusdial ager Data T ISSUED BY:_
OFFICE