24596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT' PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJF.CIIUEN'1'IF'ICATION 24596
BUILDINGADDRFSS: yw.a ���### SANITARYNO. APPLICATION SUBMITTAL DATE
e Hoa1,E 8?�tp # LOT#
OW BRSN ME: PHONE: CON CTOR'S NAME: LIC NO:
S N/C ^1 1 CONTROL.#
NCRCI LIC NO: ADDRESS:
CONTACT: Pxorve: eC7 Wi BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG CLUMB MECH
PERMIT ISSUANCE e
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RISIDliNT1AL
pCZ Ihaebyaffumlhat lam licensed under provisionsof(Chapter 9 hommeningwith JOB DESCRIPTION
uF100F. Section 9000)of Division 3nf the Business and Pro[nsinns Ctde,and my liemxls in PANELS r
C W U full force and efICCL
FZW Date eClan= _ C.P TO A '
yu,ti Dom GOpTSDECLARATION
0 _
z0o,- ARCHITECTS UECI.ARAT ON B NIAMP SO.IT.FLOOR AREA E/SQ.1T.
O Z—O I undctsmnd my plans shall Ix used as public records.
fV�
1,— "'Ij Licensed Yrol'cssionul SIGNS ELL'CT 1
iKYC2 OWNER.BUILDER D17CLARATION SPECIAL CIRU ' IS
KOaU I hereby affirm that I am exempt from the Contractor's License taw for the
i1FLLON following reason.ISeellon 70115,Business and professions Code:Any cityorcoumy TEMP.MFTE O LEINST.
Ng which requiresn eernv m convma,alma improve,demolish,file
repair any elmment
C��� prior to its issuance,also requires the applicant for such permit mfileasigned su¢mcnt POWER DEVICES
to S G O 'hot he i.s licensed Ferwunt lr the provisions of the Cournmo is Licenx law(Chapter
aaom --
9(commencing with Section 7")of Division 3ofthe Business and Professions Code) SWIMMING POOL F,LECTRIC
Xmtr' nr]hut he is escort therefrom and the basis forthc aIle ed exemption.An VALUATION
m_w g yvioladon of
FZ¢ Section 7031.5 by any applicamfnra permit subjects the applicant m a civil pcnnhy of OUTLETS-SWITCHES-FIXTURES
a no;more than five hundred dollars($5W). MIALECTR S FT. Lq
K ro ❑ I,as nwncrofthepmpedyormycmployces with wagesas lheirsolecrmpensmion, Q. 11 PE CONSTRUCTION
p�,3— willd1.the work,andthenmaureisnotintendedn ithwadsit sale(Sonecompanation. JA I
and Professions Cedc:The Contractor s Licenx Law does not apply to am owner of
pmpcny whobuildsor improves thercam.and whodocssuchworkhimselferlhroughhis % I
emploreu,provided tool mchimprovemenbarenolimendedoroffereA(msale.If, 3OC ROUY R .UNITS
In wev r,the building or improvement is sold within one yearmemarplelion,the owner. 3
I^ builder will have the burden of proving that be did not build or improve for purpr x ofTO
sale.).
AIE
❑ I.as nwneroftbc property.amexclusively contracting with licensed conlmclom to QTY. G PERMIT _ FEE FLOOD ZONE APN
orout the project(Scc.704L Businessand Prnfcseins CINe:)The Coinmcmr's
License lawdxs not apply man ownerofpropeny whobuildsorimprovesHereon.and �who uemcts for such projects with o eoorrow(s)licensed pumuanuothe Contractor'sLicense law. T-WATER jsoO FEE SUMMARY
❑ 1 um exempt under Ser. ,B&P C for This rcnon BACK II,OW PROTECT,DEVICEOUTSIDE FEES
r� SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION ONDECselfi DN SCHOOL TAX Y N
Ilmxby affirm thalhaveacenificam o!<nnsenno self-insure,oracen.It of FIXTURES-PER TRAP RIiCE1PPp
orkeri Compinsatian Insurance or a cenifed copy therof(Sce.3800,Lab CJ which PARKF yE Y
covers all employee's under IM1is pemtil. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Company
Policy# BUILDING DIVISION FEES
Cany
❑ CenificJ copy is hercny(umisM1ed. GAS-F.A.SYSTEM-OVER 4(EA) PLANCHECK FILE O
❑ Cenified copy is tiled with the city inspection division. GREASFpNDUSTRL WASTE IN]'ERCEPI'OR GRADING FEE
CERTIFICATE,OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisxnion need nrn he consplemJ if the pemtil is far one hundred dollars($100) SEWER-SANITARY-STORM EA.20(1 ENERGY THE
or less.)
I certify that in the performance oflhe work for which this permit is issued.I shall WATER HEATER W/VEWZLL"R
not employ any Pe vnY m' or y m b�`ysubmet la the Workcraro' PAID
z Compensation J,.awy of Cayfanyr ;,,; `-1 YY i0
WATER SYSTEMMrATING
C APplicum (,�( (�.Jpf, Receipt If
z 0 NOTICETOAPPLICAM':ILofmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Fy becmmesubject ,,,he Worker's Compensation provisions of the Labor Code.you must ,�''jj I
fonhwith comply wi lh such provisions or ibis pami l shall be deemed revoked VRI�Of�M Ii Q Q BUILDIN--E �e
pis Q CONSTRUCT ION LENDING AGENCY I S' - �.� SEIS C
Z) Z IM1crcbyaffirmthatherciseconstruaionlendingagencyf�rlhcperformanccof11 F1
I) O the work for which Ihis permit is issued(Sec.3097,Civ,C.) T ELECTS IC TEE O
0 L) Lenders Name -
Lemba's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W 1 certify that I have read this application and state that the above information is
(~ Q' carttl.]agreemcamply wilM1all<ilyend county oNinances and tate lawsrelating to PERMIT ISSUANCE .0`0MECHANICALFEE
_ � building construction,and hereby authonce representatives ofthis city Pecmer upon the
U Z uh—C-Pensioned property Iia irmpaClom purposes. ALTER OR ADD TO MF,CIL CONSTRUCTIO X
(We)agree to save,indemnify and keep hornless the City of Cupen into against
Iinbi l ilics,jud,ound,costs x
un pens.which may in any wayaccrve again City AIR HANDLING UNIT(TO 10,00o CFM)
In LOn
c [thea dfi lhis permit
w 09 A IS II ANGLING UNIT(OVER 10.000 CI'M)
et o Ap aMl/Cnmanor / pale EXHAUST HOOD(W/DUCT)
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dae Rcccipt#
as Will these Cu tomo Municipal CodeeChapte 9,12,and to M1Hardousmamorl
flyCdetiSee ,, the32w)?no Municipal Calc,Chapmr 9.12,and the Health and Safety HEATING UNIT(OVER IW,000 BTII)
Code,Section yest )?
❑Yes IYNo VEM'l1.AT10N FAN(SINGLE RESID)
Will the applicant or future building occupant use eyu ipmenl or devices which emit BOILER-COMPLIGPOR IW,IXKIB'rU) U$j$$UA CED TE
Kiiardous air contaminants as defined by the Bay Arca Air Quality Management
Di,rocR BOILER-COMP(OVER 100,031)BTU)
BTU) IP /y '
❑Yes No NEW RESIDENTIAL MECH. SQ. T.
1 have read the baenot ous materials reyuircments under Chapter 6.95 of the FEB 1 1993
California l Icalth&Safety Code,Sections 25505,25533 and 25534. I understand thin
if the bui lding does not currently havetenant,that it is my responsibility to notify the
occupenl of the yuiremems which muyl pe meI"new iss y of Cenifcas of CITY (�r VULC„1 In
Occupancy. l.!/`y#!-(��+. )y/Uvfy ��J/��/>jy�j(�
Owner or aulhoneed age Dam 'T ' ISSUED BY<y�CY=#' 1 /
OFFICE