24563 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO H ILOING-ELEC'TR[CAI. PERMII'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. /� A r^I�
BUILDING DIVISION BUILDING PROJECT]DEN'T'IFICATION L 4 5 l6 3
GILDING ADD E'S: SANITARY NO. AI'R^ICA'I'ION SUBMITTAL DATE
I OQ� UNITN 1.0'1'# I (/g�2
SNAME: PHONE: rADDRESS N/C CONTROL#
all
ITELT/ENGINF.ER: hIC N0: `C ❑ 1 CIYONTACT: PHONE:Ll � ELECTRIC PERMIT FEE PERMITINFO/"'V !\.Z✓,_^7A,= P I C`J �f��� SSUANCE I�LICENSED CONTRACTORS DECLARATION CES-RIi51DTiNT1AL LOB UFSCRI ION
azz Ihereby affrm mat l am licensed under provisions ofan,aner9(commcingwinhKO0 Section
i�inOd ofccvision 3 of the Business and Professions Cade,and my license is in O .*
F 7IL Liccnm Cl Confront, ac ac UP T02W Ah1P5 ��� �/�
HQy Dam GVZTSD _�_ 201-I(X1U AM
ZQNZ ARCHITECTS DEC RA Ot OVERIIIUTAMPS �_S='F1'Fl"(�A Og/SQ'FE
OZ4O IundcrstnnJ my plans shall be umdazpublic records. ;e-%if/a3
SIGNS ELECIR
yf.,] licensed Professional s
y.KG OWNER-BUILDER DECLARATION s SPF.CIA CUITAUSC.
X C W U I hereby affirm that 1 am exempt from the Consomme',Licem a Law for the
�40`D following...(Section 7031.5,Business and Pmfemions Cole:Any city or county TE .METER OR POLE INST.
F"�,� which requires a permit to construct,alter,improve,demolish,or repair any structure
pdono it issuance.al..sorequires theapflicam for such permitto file a signed statement POWER DEVICESw� ,0y that he is licensed pursan
ano the provisions of the Contractor's License Law(Chapter
dyeLL 9(commencing with Section 7") Division 3 of the Business and Professions Code) SWIMMING POOL ELIiCBIC VALUATION
w=h Setts he is 7031.5 by any applicant for
the Point subjects the appi cation. coviny I Enalty of UTLETS-SWITCHES-FIXTURES 2t9 Q� mar/
�z< ranSection' bran v any ISSUrmin subjects the upplicam to acivil penalty of 1
rot morethan rofthe rodny,ormyeWy NEW RESIDINTIALELECIR _SQ.ET.
CFo ❑ othe%m .said
ermyempindedor fferedorsale(Sec.compensation, STORIES TYP CONSTRUCTION
a3=° will dnthewons oar the s[ntctumisnot is Lndese Low
not apply to sm Business
and professions Coda:no Contractor ndwho Law does not apply tow owner iif
s
property wyees,prsodimproves hat such impr andwho doessuch work bimmlfof through his
own Cmployebuildigorithus wchlmpmv.m.ntsarcne fear ofdmoffeon.be own If. OCC.GROUP RFS.UNITS
however,the have
the or improvement is sold within one year of completion,the owner- .
builder will have the harden of proving that he did not build or improve for purpose of
ale.).
❑ QTY. PLUMBING PERMIT FEE FLOOD ZONE ppN
construct the project(Sec.7014,Business and Profess ons Code:)The Contractor's
License Lowdoes not apply In an owner ofproperty,who builds or improves thereon,and PERMIT ISSUANCE
whocancrcts for such projects with aconunrts) LIZ
aulicensed pursuant tumeconuacmr': ALTER-DRAIN&VENT-WATER EA
License Law. WATER(E) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLOW PROTF.CI'.DEVICE OHI$1DE FEES
SANITARY YN
Owner Dam 1 DRAINS-FLGOR.ROOP,AREA OND. ��' RECEIPT#
AT
WORKMAN COMPENSION DECLARATION l SCHOOLTAX YN
47 In hereby affirm that I have a certificate of eomm�no self-insure,can emtificam of RECEIPT#
FIXTURES-PER TRAP
orkmi Comprnmonlnsammeor racerificJ copy thawf(Sec.3B00,Lab C.)which `r PARK FEE Y N
coveall employeessunder this permit. GAS-F.A.SYSTEM-1 INCA OUTLETS DIVISION
Policy Its BUILDING DIVISION PEES
Co. say
Certer-ified copy is hereby famished. GAS-EA.SYSTEM"OVER 4(EA) PLANCI IECK FEE
Certified copy is filed with theecity city inspection divisionGRE I T L S :IN E GRADING FEE —�
CH TIFICATE OF EXEMPTION FROM WORKERS' OR SE'1 A SOILS FEE Q �!
COMPENSATION INSURANCE
(This section need not be completed ifihe permit is for nine hundred dollars(1100) SE R-S NfiJW+ 2 LFT I ENERGY FEE
or lam.)
I cenify that in the performance oflhe work for which this permit is issued l shall WA'T'ER UFA
W/VE /F,
of employ any person in any manner so az m became subject m the Workers #Alp
z Compensation Lawsof Califomia. Dam WA'T'ERFV� Dam t
0 O Applicant
NOTICETOAPPLICANT:If;after making this Certificate of Exemx
ttption,youbould NEWRESIDENTIALPLMIL SQ.PL
F rn become subject the Worker's Compensation Provisions of the labor Coda you must TOTAL:
� ; fonhwllh comply with xucM1 provisions uritis permit shall be deemed revoked BUILDIN P'E
pW, Q CONS,RucriON LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that hem is a construction lending agency for the performance of ��
(� O the work for which this permit is issued(Sec.309],Civ.C.) T ELECTRIC FEE 0
tenders Name
00 U Lendcr'x Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I unify that 1 have mail this application and.nate that the above information is
r1' W carred I agree to comply with all city and county ordinances and state laws reining to PERMIT Pte[PERMIT ISSUANCE ��
F' h tomidingmmormlion,and hereby authorize re enmtives ofthiscity to enter u,son the
V z aluwc-ntentiome openy fm inspenio pu x ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)a to save,inde k p trzrmless the City of Cupcnino again.a
lUdalitie. gmen cost ichmaymanywayaccrueagainst id City AIR HANDLING UNIT('1'O idyl CFM) �•
ueace
omit.
AIR HANDLING UNIT(OVER 10,0(1(1 CFM)
Si sere of ApplicI pate EXHAUST HOLD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNII'(TO 10HOHO BTU) Dam Receipt#
Will the affliction or future building occupant score ar handl.h...moua material
as defined by the Cupcnino Municipal Code.Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT
CcMe.Sueniom 25532(u)1
11 1
11 Yes ❑No VENTILATION FAN(SINGLE RE OD)
Wil)Neapplicantorfotumbuildingmeupmtumequipmentordeviceswhichemit BOILER-COMP(3HPOR 1001 OBTU) r
ISSUANCE DATE
so,ordou.s air contaminants its defined by the Buy Area Air Quality Management
•strict^ BOILF,R-COME(OVER 10B0(IO BTU) M I D
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. AWn/
I have mad the hazardous materials requirements under Chapter 6.95 of the WAR -5 1993
California Heelth&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if nhc buildingdoesnot currently have a tenam,that in is on,responsibility to notify the CITY Ur
occupant of the requirements which most he met prior 1.issuance of a Cer ificale of
Ixeapan.y.
Owner or authorized agent Dae TOTAL
ISSU[D BV:
OFFICEo