24730 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- ,LECIRI AL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
If UI LUING PROD RCT IDENTIF'ICAI ION
BUILDING ADDRESS: �. !� SANITARY NO. APPLICATION SUBmUTAL DATE
`1sA,06t kw`'\V— �M.UNITT# LOT# (-I��3
OWNERS I'I10NI?: CONTRACTOR'S LIC NO:
N/C CONTROL#
ARCHITIiCl/ENGINIZER: WC NO: ADDRESS: 60 ` ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEB. BUILDING PERMIT INFO
BLDG ELECT PLUMB MECR
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
I hereby affirm that l am licensed miler omofChat 9 JOB DP.SCRIM ION
CWOO Y provisi per and
my ficengwith
�OO Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in pANEIS 1 �K ,�
Liesurbdificurceandeffect. UPT0200AMPS ` V1
Z License Cress Lia.p
y<y Data Convenor 201-11100 AMPS
SFO N'� ARCHITECTS DECLARATION OVER IWOAMPS Q.I L R $/SQ.FT.
I unreretmd my plans shall be used as public recaNs.
�r :J SIGNS ELECTRICAL M P U T E R
¢yE� Licensed Prafessionel
°CyUl< OWI am eseILUERDECe Cisom me SPECIAL CIRCUIT/MISG
a�dOyF 1 hereby affirm that 1 am exempt from the Convenors License Law for the
W3Oy fallowing reusaa(Scctinn 1031.5,Unsinene and Prnfineiona Cole:Any city err county 'I'IiMI'.METER OR POLE INST. DATE
which requires a permit to convect,alter,improve,demolish,or repair any structure
;!ITS prior to its issuance,also requires the applicant for such perm be file a signed statement POWER DEVICES
mai<p that he is licensed pursuant to the Provisions ofthe Contractors License Law(Chapter
aXQ� 9(cammencing with Sethi 7000).!Division 3r Ne Hinmess and Professions Code) SWIMMING POOL ELECTRIC VALUATR&
❑y ortlmt he is exempt therefrom and No basis fonheullcgel oxemption.Any violationob 0l1'IT f?'TS-SWITCHESFIXTURfi9
- 4 Section 1031.5 by any applicant for a peorth subjects the applicant to a civil pari of - \ ` i♦ ��
not mare than Five hundred dollars($500).
KK m ❑ I,ssownerofthepmperryarmyemploye<awiN wagesaztMirsalecompertsninn. NEWRIESIDENTIALELECR _SQ.Ff. STORIES TYPECONS'IRUCfION
y3� will do the work,and thestmoure isnot moodedoroffered for sale(Sec.1044,Business
and Pmbession,Code,The Comanm's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself orthrough his
awriumployars,provided thmsuch improvementsare not intendedor offered batiste.If. OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofcomplation,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
We.).
❑ I,as ownerof Ne property,amexclusivelycommeting with licensed contractors to QTY. PLUMBING PERMIT FEE PLOOD ZONE AI'N
consumer the project(Sec.7044,Business and Professions Code)The Contnaor'x
License Lvwdoesnm apply to anowncrofpropenywha buildsarimproves thereon,and PERMIT ISSUANCE
who contracts farsuch prejectswidu aconamemans)Bonnard pursuant to the Comucars ALTER IEA)
License Law. FEE SUMMARY
❑ 1 um exempt under Sec. ,D&P C far this mama BACK FLOW PROTECT.DFVICE OILESIDITTYM
SANITARY Y N
• Owner Data RECEIFTp
DRAINS-F1.00R,ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ lhertby affirm Nm thecae ecenificem ofeonsem to self-inxum,oraanificate of FIXTURES-PER TRAP RECHIPT#
Wodcts'Campensation lnsutamcm.certified copy thcomf(Sec.3800,Lab C.)which PARK FEE Y N
covers all employed,under this permit. GAS-BA.SYSTEM-[INC.4 OUTLETS RECHIPP#
Policy# BUILDING DIVISION FEES
Company GAS-E.A.SYSTEM-OVER 41G) PLANCHECK FEE
❑ Cmlfied copy is hereby famished,
❑ Ccoifted copy is filed with Ne city Impaction division. GREASEANDUSTRL WASTE IN'T'ERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPITON FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisaeerion need not be completed if Nepermit is finance hundred dollars(S100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or less.)
I cenify that in Ne performance of the work for which this permit is issued,l shall WATER HEAT ER W/VENT/ELECR
not employ any person in any manner so as to become subject to the WorkersPAID
z Cmi,mmim Lawsor Califumia. Data WATER SYSTEM/IRGTING Data Receipt If
Applicant
� Q NOTICE TO APPLICANT:IL.fRrmking this Certificate ofFsemphon,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
fn beooma subject o the Workers Compansmlon provisions ofthe Labor Code,you must
forthwith comply with such provisions or this Permit droll be deemed revoked. BUILDING FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC HE
7 z I hereby affirm that there is a construction lending agency for lM performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
w. ELender's Name PLUMBING ME Lender's Address QTY, MECI IANICAL PERMIT FEE
I certify that 1 have read this application and stem that the above information is
7" 0. coma.I not to comply with all city and cowry ordinances and smote laws rehiring to PERMIT ISSUANCE MECHAMCAL FEE
building convection,and hereby audimise represematWes of Niscity m eater upon the
U z ahove-me)tare p save,indemnify
mnify ion purposes. ALTIiR OR ADII'fO MECR.
CONSTRUCTION TAX
(We)agree nt save,indemnify and keep hmy in as the City of Cupertino against
or ,,itiu,judgmf h casts and expenses which mayinany way ace a�g set AIR HANDLING UNIT(TO IO,OOB CFM)
in can ce of the gmming of Nis it.
AIR HANDLING UNIT(OVER I O.WO CFM)
A4Le ie
Signamrc of Ap am 'om vrmr Date EXI IAUST FOOD(WIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I IL"BTU) Data RecciptIf
Will the applicant or human building occupant store or handle h mandous material
as refined by the Cupertino Municipal Gds,Chapter 9.12.and the HeaOh end Safety HEATING UNIT(OVER I DcLOW BTU) TO a'
Gude,Section25532(ap
11Yes CI No VENTILATION FAN(SINGLE RESID) `
❑
• Will the aconta contaminants III
building by be Bay Area Air Quality Managemech nt
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazeNous air conmminants ss defined,hy the Bay Arca Air Quality Management BOILER-COMP(OVER IIgI,Ufl(1HTU)
Distrix?
❑Yes ❑No NEW RESIDENTIAL MECR. SQ.IT.
I have read[be hazardous malerials requirements under Chapter 6.95 of the µ! U
California Health&Safety Cele,Sections 25505,25533 and 25534.1 understand that
if thin building does nd cur ugly hove a tenant,that it is my responsibility to notify I `
m cupam of the re,no mm�ts which must he met prior m issuance of v Cenificam of FEB 19
Occupancy. ,.
95)
Owmrnrumhariud agent Date TOTAL: ISSUED
OFFICE r