24604 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELKC'I RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24604_
BUILDING DIVISION BUILDING PROJECT D)FNT JMCATIOry
BUILDING ADDRESS SANITARY
' �,$,�^ - SANITARY NO. �1SUBMITTAL DATE.Ic)(00 `^& r (/`'' UNIT# LOTp �,APPLICATION
8 � 4
OWN' Ne)ME: PHq;sE: CONT NA F Zj�O0' v ` l
.� N/C CONTROL#
•ARCHITEC7GENGINEF,R: LIC N0: I ADDM6—C __ ❑
PHONE: QTY (_�ELECTRIC PERMIT FEE BUILDING PERMIT USED
BLDG F,.E�;@ PLUMB MECH
PERMIT ISSUANCE, p El
CENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nxz I herebyaffircensed under Provisions of Chapter 9(commencing with BOB UESCkII'1'ION
m Net l am licensed
1+100 Semina 0000)of J of the Business Professions Calc,and my license k in PANELS
on
cul LamI... full force node Lr � I
Ezy Liccnx Cl Lisp UP T02W AMPS
y 6 N Dam Commcmr 201-1000 AMPS
,ON'_ D'-1 ARCHITECT'S DECLA ATI N SQ.DT.FLOOR AREA $/SQ.FI'.
OZ—O I understand my plans shall lc used as public records. OVER Ron AM15 /� lI II
<Y[— SIGNS IiLECIRICAL r 8 III` p /.1 II �-
Q �� Licenud Pmfcssional N!O,VII A Lk.. IIS,_•
"�6 OWNER-BUILDF,R DT:CLARATION SPECIAL CIRCUITR.115C.
kOOF 1 hereby affirm that 1 in.cxempr from the Contmcon's License Law Rothe aasonf3 .n J -
n1'%a`n followingo .(Section7031.5.BusinessandProfessionsCode:Anycityorcounty 'I EMP.METER OR POLEINST, J IOIV/1
which requires a permit to consumer,alter,improve,demolish,or repair any structure
,,Y no its issuance.also re then liwm forsuch no flea si dstamment POWER DEVICES
prix quiets pp pract gLa
pj K C O Jut m is licuti ng w pursuant to the provision;of the Ce Business
License Law r1 hapterCode) SWIMMING POOL ELECTRIC
dXODATE
LL 9t that
be iscsrmiNSection mnrud iv Division3of sheecd rsemand Frohn 6.1s Code) ,
rn onhmbcix1.5 bya yaptuimmW the basisf cube is the exemant If civilp raltyof OUTLETS-SWITCHES-
f E< not mmo
than bye hundred
collars apcnnit subjects the applicanno ecivil penally of FIXTURES
not more court c hundred dollars yemp.
�F_o ❑ I.ns owncrofNc property,or my cmployccswith wugcsasthcirsolecompensaGon, NEW RESIDENTIAL F,LECfR SQ.FT. STORIES TYPO:CONSTRUCTION
and du Ncwons and,The Contractors
License
Lae dos not apply t an Business
and Professions Calc:The Contmcton.License Law does not apply m an owner of
ownpropertym whebuildsorimprovox IM1empr and who does otsuch imworkhimselfunitmugb his
employees,provided that suchimprovemenu are notimrndcdoroffend Tarsale.If, OCC.GROUP RES.UNITS
however,the building mimprovemem is sold within one yearofcnmpletmin,the owner- TOTAL:
builder will have the burden of proving that hedonist build ar inrpmse for pu,,,,e of
sa1c')' QTY* PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las the p ofthepropcny,amexdusivdycomractsious oda)wdronveaorsro
construct the project CSec.")ano Buninesn and Rofersi ild Crimp ove thersContnemr'x
Licensetrawdocnnotappffects ow ncrntruclenywhosedp orimprovesthereon,and 1'ERMI'1'ISSUANCE
who contracts forsuch projects with aamtracmrTx)licensed punvum m the Contractors
License Law. ALTER-DRAINXVBNT-WKfER(IiA1 FEE SUMMARY '
❑ 1 ten exempt under Sec. ,B&P C for this mown BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPTa -
DRAINS-FLOOR.RDE.AREA,COND.
WORKMAN COMPf:NSATION DECLARATION SCHOOLTAX YN
Iherehyafnesium llhrance orta team of amsemereof inm3MXl. d,C.)muteof IIXTUNEd-PBk'1'RAP kECF.IPI'#
Workers Cumpcn'tion Insurance orvccn'fieJ copy Nertof .3g00,lab C.)which PARK FliIi Y
overs all RECEDIO#
,�3q� GAS-IiA.5Y5TEM-1 INCA OUTLETS BUILDING DIVISION PEES
Policy p
�Ce-Prov Z GAS-EA.SYSTEM-OVER 4(CA) PLANCIIECK FEE
❑ n fled copy is hf by�m,Irrd.
iGcd copy ix fled with the city inspection division. GREASMSOUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sertwomedirm be completed ifdc permit is home hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY ME
or lass.)
I cenit'y that In the pv,k..mm.mofthc wink In,which his permitNiasmd,l shall WATER HEATER W/V5NT/EI.BCIR
nm employ any person in any manner so as to become subject no the Workers PAID
Compensation Lawsof Califomia. Dale WATERSYSTF,MOREATING Date Rmcipt#
z2 Appbcmt
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,I7. TOTAL:
fn become subject to the Worker's Compensation provisions of the labor Code,you must
forthmit with comply with such provisions or this pershall be deemed revoked. BUILDING FEB
Rwi Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
U z I herebyvffirm that there is aconsbuctjon lending agency home performance of 'I'Oy'AL: L'LECTRIC MEO Nec
e work for which this permit is issued(S .3097.Civ.C.)
Lender's Name
u"' F Lendves Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
LUQ correct.
modify that 1 have read this appliwdon and sum Nat rhe above infortmJcars _
MECHANICAL FEE rnrrca.Iugrce to comply with all city and county ordinances and stain laws relining to PERMIT ISSUANCE /
F-' n' building emstructian,and herebynuthoriu represennovesof Nis cieym enter upends
V] CONSTRUCTION FAN
U z a6ovememioncd pm inspeminn purposes. ALTER OR ADD TO MECH.
(W e)agree t - sonify unJ keep harmless the City of penia against
liabiluies,j cost "expenses
which may io wy way uga' t aid City AIR HANDLING UNIT BTO 10,000CFM)
cu ting of this permit / AIR HANDLING UNIT(OVER 10,000 CFM)
Signatu fA mUComraetor :�/-f late EXHAUST HOOD(WNUCT)
PAID
• HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTI) Date Remno#
Will the applicant or future building occupant store or handle hazardous material
ns ddined by the Cris n so Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Cale Section 25532(a)? VENTILATION FAN(SINGLE RFSID)
13 Yes ❑No
ISSUANCE DATE
Will the applicant or future building occupant use cquipmentvrdevlees which emit BOILER-COM P CID P OR 100,000 BTU) �
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) A
District:, 4 /
❑Ye. El No NEW NISIDF.N'1'IAL MIiCH. SQ.17. n D
1 have read the hazardous materials requirements under Chapter 6.95 of the 14 9
California I leafthdo Pe ofSafetycur Cale,Sections 25505,25513 and 25534. I understand that
if the building docs not cants w have are......hat it is my responsibility m our,the
occupant of the rcyuiremevs which must be ma prior to issuance of u Coni[Icme of Chi
Occupancy,
V
Owner or avthmizal agent Date TOTAL: ISSUED BY
OFFICE