24964APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
CITY OF CUPERTINO- G- . ELTRI A, PERMITNO.
APPLICATION/PERMIT PLUMBING - MECHANICAL, n A A
BUILDING DIVISION �C
BUILDING PROJECT IDEN'TIF'ICATION L 4 o 4
BUILDING ADDRESS:
L SANITARY NO. APPLICATIONSUBMHI'ALFR i
��N y
,
UNIT# LOT» 14)_-73
O ' 5 AME,: /� P}IONE: 4!lp�-- CONTRACTOR'S NAME: LIC NO: NIC CONTROL#
,C f T V.SS (c r yry -
RCIITECT/ENGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
-
PERMIT ISSUANCIJ
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL JOB DESCRIPTION
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I hercbyaffirm that l sm licensed undcrpmvisiomofChapter9(commencingwith
J400
Section 7000)of Division 3 affix Business and Profusions Cale. and my license is in
full force and effect.
PANELS
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6
LicenseClass Lic.#
Data Contractor
UP T020o AMPS
oLLe L-0
y y
201 - 1000 AMPS
'$/SQ,
ARCHITECTS DECLARATION
20mz
OVER IOM AMPS SQ. FT. FLUOR AREA IT.
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Iundcmm�d my plans shall be used ¢v publi<rccords.
F rn;
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
C) U
I hereby affirm than I un exempt from the Contractor's License Low for the
W3LLy
following mason. (Section 7031.5, Business and Professions Cale: Any city or county
TEMP. METER OR POLE INST.
which requires . permit to mostimi else,, improve, demolish, or repab any atmcmm
prior to its issuance, also requires the applicant for such Permit o file aligned statement
POWER DEVICES
W a 0Os
licecd pimmi m to the provisions ofthe Contractor's License Law (Chapter
But he is m
a �LL
9(commencing with Section9000) of Division 3 ofthe Business and Professions Cade)
SWIMMING POOL ELECTRIC VALUATION DQ
y)�,n
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Senion 7031.5 by any applicant for subjects the applicant civil of
OUTLETS - SWITCHES -FIXTURES J D 0 I
�z¢
permit penalty
o t an five hundred tlollan (5500).
Cmn
Lmowneroftheprnpeny.ormyemployaswith wagesm theirxlecompemetian,
NEW RESIDENTIAL ELECIR S .FT.
Q Sl'ORIES TYPECONSTRUCTION
y
will do the work,andthe amorturc i ... tinUndedcraffvd fursale(Sec. 70,14, Busm.
and Professions Codc: The Connector's Liccna Law does not apply to an owner of
property whobuildscrimpmvesthercon, and whadoessuch work himxlforlhmugh his
ownemployms,provided Ihatsuchimprovcmenu arc notintendedoroffercd fora¢le. If,
OCC. GROUP NES. UNITS
however, the building mimprovemem is sold withinone yearofmmpleuon. the owner.
TOTAL: V r
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I]I,mownerofthepmpeny.amexclusivelyconvactingwiNlicens cmusctmio
\�
QTY. PLUMBING PERMIT 1•L'E ILOOD20NE AVN
conswa the project (Ser. 7044, Bminess and Professions Cade:) The Contractor's
Ucenx Lawdoesnot Wlymanownerofpma nywhobuildsorimprovmhercon,and
PERMIT ISSUANCE,
afonuchprojecuwiNeconwaorts)lic<nxdpursuenuothe Conwdore
Uanx L
Lice. Law.
ALTER- DRAIN ffi VENT- WATER (EA) FEC SUMMARY
❑ I em area s t under Sec. , B ffi P C for this reason
O SIDfi FEES
BACK PLOW PROTECT. DEVICE;
SANITARY Y _N
Owner JZ
-
RE.CEIPI'p
DRAINS- FLOOR, ROOF, AREA, COND. SCHOOLTAX YN_
WORKMAN COMPENSATION DEC N '.. / jj
❑ Ihercby effvm thaU have ecmificam ofconscmmsel man nrecenifcem r
FlXTURES-PER TRAP RECEIPtp
Workers, Compsoation I..ce ma certified ropy thereof (Sm. 3800, Lab C.) which
PARK FEE Y N_
coven ell employee's under this permit
GAS - EA. SYSTEM -1 INC. 4 OUTLETS RECEIPT -
Policy #
BUILDING DIVISION FEES
- EA. SYSTEM-OVER4(EA) PLANCHECK FEE
❑ComCertified copy is hereby famished,GAS
_
❑ Canned copy is Bled with the city impaction division.
GREASETNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FI'. ENERGY FEE
(This socarra cednot becompleted if Ne permit is burns, hundred dollars(SI00)
to Ies9.)
WATER HEATER W/VENDELECTR
I entity that in the perfomunce of the work for which this permit is issued.)shall
not employ any person in any manner m as to become subject to the Workers'
PAID
z
Compemetion Uwsof California. Dam
Applicant -
WATER SYSTEM/IIIEATING Date Reccipt#
Q
zz�-1 0
NOTICE TO APPLICANT: If, after making this Canlficamof Excmption,youshould
NEW RESIDENTIAL PLMB. SQ. FT. TOTAL -
OTAL:V)assume
V)
assumesubject in me Worker. Compensation provisions ofthe labor Ccdc.ym ..at
F�.7
forthwith comply with such provisions to me
this permit shall be deed revoked.
BUILDING FEE -QD
W Q
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
z
I hereby affirm that more is a com octim lending agency for the performance of
CeCe�JJ�^
O
the work for which this Permit is issued (Sec. 3097, Civ. C.)
TOTAL: ELECTRIC FEE
D.
Udders Name
Under, Address
QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
0.
I mail that I have read this application and sure that Bre above infomuBrn is
correct. ler es, to cont with cit and ordinances and stem laws mining to
gs comply wi yen county g
PERM IT ISSUANCE MECHANICAL FEE
�
buildingconstruction,herebyauthuiaxoses. dvnof Nis citymcntaupon @<
CONSTRUCTION TAX
(� 'z
above-nuntioned properly for inspersion
ALTER OR ADD TO MEET I.
keryosa.
(We) agree m save, indemnify and kap harmless the City of Cupertino against
•
s
liebilitiu,jud nu, costa and expenses which may�yway eccaeegeinst said City
AIR HANDLING UNIT (TO IO,UO CIM)
Doxy o h antingof Nispennit. it
A /C/
AIR HANDLING UNIT (OVER IU,IXNI CFM)
EXHAUST HOOD(WMUCT)
Signature of ApptidansConcremon Dao
PAID
HAZARDOUS MATERIALS DISCLOSURE ���
E
HEATING UNIT O 1011,0(0 BTU) Dox 0.eccipt#
(T
Will the applicantor. building material
Mu xis,Cantstoreor and the Humba
m defined by the Cupertino Municipal Code, Chapter 9. 12, and the HnIN end Sefcry
HEATING UNIT (OVER 100,0010 BTU) TOTAL:
Coda Section 25532(e)P
❑ Ya ❑ No
�q
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
Willtheacommntorfuture building
e.
BOILER- COMP QHP OR 100400
Air Quality
h vir cantmivnta m defined by the Bey Arca Air Quality Management
by the
pp pp•��
BOILER - COMP(OVER 110,000 BP A I V
imnet?
I]tr1e14 '
❑ Yea ❑ No
NEW RESIDENTIAL MECH.
I have rend the hauNous materials requixmenu under Chapter 6.95 of the
APR 121993
KTOTAL:ISSUEDBY:,�-
Celilomia health ffi Safety Code. Sections 25505, 25533 and 25534. I understand that
if the building don not cunt n ly have a t#mnt that it is my rupomibility to notify the
occupant of the reyuimments which must ere met prior to issuance of a Certificate of
CI I Y 'Ur CUrrn 11140
Occupancy.
T�PIIKLI
Owner err authorized agent Dux
OFFICE
' A