24666APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELERI AL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDIEWIFTCATION
PERMITNO, 24666
BUILDING ADDRESS:c
SANITARY NO.
API'LIGTION SUBMITTAL DATE
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OWNtiRs ME: rG0 PII NE: CON&=R'S NAM': LIC NO: V/.
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CONTACT: PHONE:
QTY. ELF PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT LIJBC 1
3 o PERMIT ISSUVJE
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LICENSED CONTRACfOR'S DECLARATION APp q S JRESIDENTI
Iherehyaffmr Nmlam licensed underprovisi.nsofClupter9(c.mmencing with
Seaion 9000) of Division].( the Businessand Professions Code,and mY license is in P
full force and effect.
License Class Lic.p P 0200AMP
Date Convector 1 1 Mp,
MOTION
-
ARCHITECTS DECLARATION VER I MP
l understand my plans shall beuxd. public records.
SIGNS AL
tT. FLOOR pRF,A
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Licensed Prafusinnel s
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OWI son c ermlBUILDLR\ SPECIAL UIT SC.
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I hereby affirm that I um exempt from rM1e C.mrncmr'a Limnse law far t
reason. (Section 7031.5. Business and Profusions Cale: Any city armory TEMP. METER R POLE INST.
which requires a perout to construct, alter, impress, demolish, or repair any structure
to its issuance, also remixes the applicant for such permit o rile asigned statement 'POWER DEVICES
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter
9(commencing with Section 7") ofDivision 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC
or that he is exempt therefrom and the bast,form,ttileged esemprlon.Anyvl.lm oermf
Section]OJLS by any applicant(mupetmit subjenathe+pplicantmacivil penalty of UTLEfS- SWITCHES - FIXTURES
not more than five hundred dollars (9$00)' NEWRCSIDPNTIALELELTR_SQ.FT.
❑ I,esownerofrM1epropcny,a myemploYceswirh wugesutheinolecompensation,
ak�
VALVA CV
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STORIES 'PYPECONSTRUCTION
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will do the work,and the swcturerisnot incralmoroffered hostile (Sm. 70,14, Business
and Professions Cale: no Contractor's License Law does not apply to an owner of
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propenywhobuilds.rimpmvesihereen,andwhodoessuchworkhimulforthroughhis
oneearofdmofRred for sand,
however, the building orlmprovemcm is said within oneyearofwmplGloo, theowner- T
howemployebuildivi or improvementsaid within
builder will have the burden of proving that he did not build or improve for purpose of
- CC. ftGU .UNITS
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1 1 I�/I 1✓ 1 II E g..,(
Mrd L V J It slJ , l
a11e.)' QTY, PLUMBING PERMIT FEE
❑ I, asownerofinepropcny,umexclusivelyconuactingwith licensed co mewrs1.
FLOIII APN
ATE�Wg
wsmom, the project (Sec. 7044, Business and Professions Cash:) The Cmucte is PERMITISSUANCELIE
L ice -se Law d«a not apply m un owner of property who hul Ids or improves thereon, ead
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who emoucis farsuch project; with acontrm:mr(s) licensed purauonno the Contractor's ALTER - DRAIN&VENT-WATER (EA)
License law.
01 em exempt under Sec. B & P C (or this reason PACK FLOW PROTECT. DEVICEIDE
PEESUMMARY
.S
SANITARY YN
REC[IPfp
Omer Date DRAINS- FLOOR. ROO11, AREA, COND.
0. WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a certificate ofconsennoself-insure,oreanifica¢of TXTURES - PER TRAP ��
Worktts C6mpensation Wumnce uracenifed copy thereaf(Sec. Jg011, Leh CJ which
Pars all employee's under this permit. GAS -G.SYSTGM-1 INC. 4OUTLETS
olicy#
SCII001. TAX YN
RECEIPT)
PARK FEE YN_
RECEI #
BUILDING DIV NFEE$
ar, GAS - EA. SYSTEM -OVER 4 (PA)
PLANCHECK FIE
Certified copy is hereby famished.
GRADINGFEE
Certified copy is fled with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY
(Thissectionnedrot hecompletedif Nepermit isforonehundreddollars($1001 SEWER - SANITARY - STORM EA. 200FT.
or lm .)
I mortify that in the performance of the work for which this permit is issued. I shall WATER HEATER W/VENTBLECfR
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not employ any person in any manner so as an become subject to the Workers'
Compeosatienlawsof Califomia. Date WATERSYSTEM[MEATING
ApplicaNOTICEp, you should NEW RE.SIDENTIALPLMIL SQ. Up
NOTICE TO APPLICANT:ILeftar making this C<nificate of P.xemdon
Date Receipt#
TOTAL:
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become subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed my.ked.
CONSTRUCTION LENDING AGENCY
BUILDING .E
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SEISMICAr
g
F.LE IC FEE
ZIherehy
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afr,. that there is a construction lending agency for the perfmmance of
the work fm which this Permit is issued (Sec. 309], Civ. CJ TOTAL:
Lerder. Name-
ALU TING F[ESo
Lenders Addreas QTY. MECHANICAL PERMIT FEE
certify that 1 have read this application and nate that Ne above information is
torten. l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE
building construction, and hereby salmon representatives of this city an enter upon the
above-mentioned property for inspection purposes. ALTER OR ADD TO MSCI L
(We) agree restive. indemnify and keep harmless the City f Cupertino against
liahilitics,judgmenrs,�oms tndenpenus which may in any eyes sagmnsssald City AIR HANDLING UNIT (TO 10,000 CFM)
MECH LAICAL FEE 2 /�
CON CTIONTAX
inc"us¢quence ofth fmntjng of this pemrit.
`x�l &11, AIR HANDLING UNIT (OVER 10, 011(ICEMI
i
PAID
Datenawre o(APPlica VComracmr Dme EXHAUST IIOODOVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT (TO 100,00) BTU)
Ua Receipt#
Will the epplicant.,future building oce,emsmm or handle hazardous material HEATING UNIT I W,l00 BTU)
on defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532nd? VENTILATION FAN(SINGLE RESID) ��
❑ Yes ❑ No
ISS AN E DATE
if
BOILER-COMP(3tIPOR 100,IX#O BTU)
Willtheapplicanrn,froarebuildingoccupamuuequipmentnrdevices which emit
hazardous air ...her nann as defined by the Bay Arte Air Quality Managemcm BOILER -COMP (OVER 100,000 BTU)
District?
P
❑ Yu ❑ No NEW RESIDENTIAL MECH. SQ. FT.
I have read the hazardous materials requirements under Chapter 6.95 of Me
'I n
FE1
California Health & Safety Code, Sections 25505.25533 and 25534. I undersmnd that
lif tfie 6irlding does not currently have a tenant, that it is my responsibility to noddy the
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occupant of the reyutemenrs which must W met prior to income of a Cettiticam of
Occupancy,
.1 V IAV
ISSUED BY
Ow. or amhmiud agent - Date T
OFFICE