24647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO R 1. I. -RLL RI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. 24647
� n4 o 4�1 ^
BUILDING PROJECT'IVENTIRCATTON L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMMIIITAI.DATE
q I q CO 7-E HADERA LN UNIT# LOT
OWNERS NAME: PHONE: CONTRACTOR'S NAME LIC NO: 1
aooaNL< q'72 . gigs N/C CONTROL
ARCHITECT/HNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
S-TEve go V we
BLDG ELECT PLUMB MECH
STEve• IX/ 1Mi 473 Sb63 PERMIT ISSUANCE: ��
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DE RIPDON
Q=z I hereby affirm that I m licensed underprovisiours of Chapmr9(commencing with ^` !T
�00 Section]GOB)ofDivision 3 of the Business and Professions Coda enen
d my license is in PANELS Y ( .
�µZfull force effect. ' UP T02m AMPS
F LµE U10 License Clmend s Lic.N
o, % Dole Contractor 201-IOW AMPS S IT.FLOOR AREA $/SQ.FT.
z O�'� ARCHITECTS DECLARATION OVER 1000 AMPS Q
0 z 0 M 1 understand my plans shall be used es Public cambia.
F C SIGNS ELECTRICAL
Licenxd Professional
6yy�QQG OWNER-BUILDER DF.CIARATION SPECIAL CIRCUIT/MISC.
Rnn 1 hereby aifum ted I um eaampt from the Common,License Law for the
W 3 0.F' fallowing reawn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to consnuct,alteq improve,demolish,or repair any muctme POWER DEVICES
P-� prior to its issuance,also requires the applicant for such Perrino rile a signed statement -
I�al ¢p that he is licensed pursuant to to Provisions of the Commerce%License Law(Chapter
9(commencing with Section 7")of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
mflun he is exempt therefromad the basis for theallc,i)cacmPtion.Any violation Of OUTLETS
`a Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of
not
y 3mo nfivehundreddollem).
C mownecofthey,ormyemwithsle compte
NEWRFSDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCIION
.. illdthe d the
struca ideradmemdRusia(S . mess
rofessams Code:The Contrmctor's License Law does artapply to mowner Of
property whmbuilds orimpmvertherear,tart.)whodues such workhimxlforlhmugh his OCC.GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for side.If,
however
builder will have the burden of promvenintgisthat hedideral uildaorimproveetiofonr,pthur,samof- TO
ale.).
❑ I,ns nwnerofthe Property.amexdusivdyconmdingwith licensed contracture to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the pmjea(Sec.7044,Business unit Rofessions Coda)Tba Comrucmr's
License Luwdoesnotapply munownerof,mi,my whobuildsor improves Herron,and PERMIT ISSUANCE
whoconttucts forsuch projects with acontrxtodid licensed pursuant to the Contractors ALTER-DRAIN&VENT-WATER(EA)
License law. FEE SUMMARY
❑ I em exempt under Sa. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUISID11.
SANITARY YN
Owner Data DRAINS-FLOOR,R F,AREA,COND. - RECEIPT#
WORKMAN COMPENSATION DECLARATION �� I S AX YN
❑ Ihereby affirm that l have ocettificeteofconxnuo self-insure,macethficnmof FIXTURES-PER TR P h V / RECEIPT
Workers'Compensation Immoralor a certified copy,thereof(Sm.3800,Lab C.)which n 6' K Y N
coversi lemployee'sundcnhispemdt. GAS-EA.SYSTEM-I INC.; E7S ' I, RECEIPT#
Policy# UILDING DIVISION FEES
Company GAS-EA.SYSTEM- VER4 A) L HECK FF,
❑ Cer ifim e.py is hemby fumimed. ,aaf.-c
❑ Certified copy is filed with the city inspection division. GRLASFgNDUSTRL ASM Lye,¢ GFEP.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thio section need not be completed lithe Permit is furore hundred dollars(SIM) SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
or less.)
I rectify that in the Performance of the work for which 0hispccmit isiasuad,I shall WATER HEATER W/VENT/ELECTR
no employ any person in�'y maturer eo os to becom b'a to the Woheri PAID
Compenrstionl.awsof Celilmc �/{s�de Il�f� i WATER SYSTEMiTREATING Data Receipt#
'z 'PPlicant /pA'D(/ftCll
z� -0 NOTICE TO AP�:If,afmr makmg this Ccmficamof E.earmm youshould NEW RESIDENTIAL.FLAIR. SQ,FT. TOTAL:
E-I LO) become subject to the Worker's Compensation provisions of the Labor Code,you must
I� forthwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE
¢LII A CONSTRUCTION LENDING AGENCY SEISMIC FEE
rte- z Ihereby affirm that then is a construction lending agency for the Performance of
o the work fur which this Permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
OLenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 cenify that I have red this application and state chit the above information iv MECHANICAL.FEE
carted.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authorice repreacntativeso(this city to enter upon the CONSTRUCI'IONTAX
V above mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify end keep harmless the Cil,of Cupertino against
limililics,judgmcnts,cons and expenses which may in any way acrueagalnst said City AIR HANDLING UNIT(TO 10,00th CFM)
in consequen�t(///���f the ing of this permit.
�/, '12 _30/qL AIR HANDLING UNIT(OVER I0,000 CFM)
Signa an Cma1mm1 pate EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Im,000 BTU) Date Receipt#
Will the applicant or future building occupied smte or handle hawdom material
ss defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM."BTU) TAL:
Cade,Sabato 25532(0)? VENTILATIONFAN(SINGLE RaSID)
❑Yes 11No
ISSUANCE DATE
Willthceppliwnmrfmurebuildingacuprm usealuipmemordeviceswhich emit BOILER-COMP(311P OR 100,IX10 BTU) pp�1 pp
hamtdma air contamimmD as defom by the Be,A.Air Quality Management BOILER-COMP(OVER 100,000 BTU) P Pe, 10
•
District?
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have mud the humorous materials requirements under Chapter 6.95 of the DEC 30 IM
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that AWL
if the building does not currently have a tenant.that it is my mi cansibiliry to notify the /,)1 I y♦
occupant of the requirements which must be met prior to issuance of a Certificateof CUI- (;Ur F n I
Occupancy.
Owner or uuthnriud mem Data TOTAL: ISSUED 6V:
OFFICE