24668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIIUILUING-RLRCIRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24668
BUILDING DIVISION BUILDING PROJECT IDEN'fIF'ICA'I']ON
BUILDING
'1 ADDRESS. (( ����'��1w�#.•yw�L oy^ SANITARY NO. APPIACA'I[ON SUBMITTAL DATE
Oro W6,.L�v3L V v- UNIT# LOT#
OWNWS +: PHONE: Ct 01SaS
EXE S; I.1 NO. S�Q
• 1` /WX�I Sao
(��'I Q qp'^�I 1 N/C CONTROL
,Cf/IiNQINEER: LIC NO: ADDRESS av w Ai Lf- Sao -:eco 'l,`-1 lei
QVa FF: PHONE: .QLTLY. aVVMV ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BDG E PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CON I RACI OR:S DECLARATION APPLIANCES-RESIDENTIAL.
B DESCRIPTION
C C I h7 )oft irm that I an Tice B.under provision nfCLnpter9(commencing with
WOO
Section]0(1(11 of Division J of be tlusiness and Professions Cade,and or,license is in PANELS
~IB 11--.. full fame and effect.op
FLpj Liccnu ass sal Lic.p 39�D UPT02WAMPS
m d y Dam�>,3. Comma-o l 201-I IXp AMPS
Z Oseejs� ARCIII'I'EC'S DECLARATION OVER 1000 AMPS SQ.PI'.1100R AREA $/SQ.11
O Z—� l underswnd my plans shall be used as public records.
zY�� SIGNS ELECTRICAL
Licensed LicensedProfessional
116�J1
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I- INAL
KO aU 1 he achy eff rd that 1 am exempt from the Cmuser r'a License Law for the
u1:e following reason.(Section]031.5,Business and Professions Core Any city or county TEMP.M[TIiR OR POLE INST'.
L'Eh O< which requires a Pennlu0 construct,ulmr,improve,demolish,m repair maty vrvemrc
F.{�{yy'Y2 poor o its issuunc.alaorequires lheapplicanl for such permit to file a signed nmemem POWER DEVICES
�L'Q' that he is licensed pursuant the provisions of the Comments License law(Chaprer DATE V CAT ON SWIMMING POOL ELECfRI
aKe� 9(commencing with Section T000)of Division 3 ofthe Business and Nelson Code) CI AI
W_H onfiat he is exempt therefrom and the basisfor thenBeged exemption.Any violation of _.../ ��
FZQ Section]031.5 by my applicant for a permit subjects the applicant to acivil penally of OUTLETS-SWITCHES-FlXT�RFS
$T. sol more Nan five hundred dollars($500),p NEW RESIDENT'IAI. .Il'.
6"L'p� ❑ Lusowncrof lhepmperty,nrmycmployceswimh wxgesase¢irsncutmpensariuv, ELfCTR S Q S'1 ORI' TYPE CONS'1liUCIWN
a3— aedIde Nework,andlhe.aru<turc is nm imcndcd ser offcrcdfm sale(Sec.](b4,Business
and Professions Core:The Comrmmr's License Law does not apply to an owner of
property who bu i Ids ar i mproves thereon.and wha does such work hi mol f or through his
OCC GROUP RFS.UNITS
own employma,providcd thauuchimprovemenu ore not inendedoroffeted Tarsale.If,
budderwthebuildingurimprovement issoldwithinoneyear ofc ilmoveon,thr,axec- T
budderwill have the burden of proving that he did nrn build ser improve far purlxtse of
sale')' QTY. PLUMBING PERMIT FEE FI OOD ZONE APN
❑ I,aowner afthe prapeny,ant exclusively contracting with licensed enmrarams to
construct the project(Seo 7104,Business and Professions Cade:)The Contractor's -
Liccnselawdoanotapplyraanuwnerofpropenywhobuildsorimpmveslhereon.and PERMIT ISSUANCE
whocontracts our such projects with econmner(s)licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER TA) FEE SUMMARY
License Law.
❑ 1 am exempt under Scc. .B&P C I'nr this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Doc DRAINS-MOOR,ROOF.AREA.GOND. RECIiIYI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
byoffirm that l have a cenificaleaonse
fcm to self-imetwora cerificateof FlXTURIS-PER TRAP RLCUIPI'
sw�✓sn06—
9M'Compensation insurance or a cenifiedeopy thetmf(See.3881 lab C.)which PARK FEE RF,CIiIP p N
eall employee's udder this permit. GAS-EA.SYSTEM-1 14.40VTLFTS
i PolicyN BUILDING DTVI. ON FEES
Company GAS-CA.SYSTEM/ER4(EA) PLANCIIECK FEE 1
❑ Cent copy is hereby famished.
❑ Cenifted copy is filed with the city inspection division. GREA$EaNDUS WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TR - SOILSFEE
COMPENSATION INSURANCE
(This section neednnt be cnnplemd ifthe Perth is roman hundred dollars(Sim) SEWER- ANITARY-STORM EA.200FT. ENERGY FEU
or less.)
I certify that in the performance of the war fnrw ich this pe.I.is issued.l shall WAT HEAT[R WNEN'T/F:LI:CfIt
nee employ any person in any mmuter so��yhh ylgect to the Wortera' PAID
Compensstiun�a(gl ei DD t� �—ll WATER SYSTEM/IREATING ate Receipt it
Oz Apphcanl
z NQ'I'ICE TOA ACANT:If.Aar nsakingthL Certificate of Eacmpion.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
1--m rte. become subject to the Workers Compensation provisions ofthe Labor Code,you must UIL NG IEE
tR 7 forthwith comply with such provisions or this permit shall be deemed revoked.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the performance of
TOTAL: ELECTRIC,
UQ the work for which this permit is issued(Sec.3097.Civ.C.)
Lenders Name PLUMBING FEE
0 � Lenders Address QTY. MECHANICAL PERMIT FEE
U 1 rerify that 1 have read this application and nate that the above information is MECHANIC,L FEE �+
correct. l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE 1 �a
I--' bung comwmion,and hereby authotim reprcsenmives of thisciry mercer upon the CONSTRUCT )NTA%
V z above-mentioned property for inspection purposes. 1 ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Caperton against
liabllitias,judgarsomensu andexpcn.ves I hlchomy in any way accru .instsaid City AIR HANDLING UNIT(TO 10,X10 CPM)
in consequence of the granting of This permit.
AIR HANDLING UNIT(OVER 10,1180 CFM)
Signmum of AppliemUContractnr Date EXI IAUST HOOD(W/DUCI) PAID
HA9ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IIXkgXI BTU) Date Reeclpt#
Will the applicant or future building occupant store or handle hamrdous material HEATING UNIT(OVER I XEpK3 BTU) TA
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532SHy## VENTILATION PAN(SINGLE RFSID)
❑Yes / No
BOILER-COMP CHP OR lOB,lXI0BTU) ISSUAN DATE
M1l the upplir for fuwrc huilding«cupam use equipmentnrdeviceswhichemit iL Q O
uir cnntuminunts as defined by the Bay Area At,Quality Mougemcnl BOILER-COMP(OVER I00jX)0BTU)
t /❑Yet; �(No NEW RPS IDENTIAL NIECE i. SQ.FT. �ANd2 .tax93
_.!have read the Imardeas materials requirements under Chapter 6.95 of the ^ �I1V IX,I�
California Health&Safety Code.Sections 25505.25533 and 25534. 1 understand that H�7 Y r
if the building docs not currently have a tenant,that it is my msponsibil'ny to notify IM1e G � curd'' µ
maul al o cots t ich must Ina ntel prior to isevunc t a nideate of
OwrI mhorimd agent �G—I Date ISSUED BY:
OFFICE