24565 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTiNO
BUILDING, .1., TRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� A /N
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 2 4 b
BUILDING ADDRESS: - SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT# t J1/yQr/
O SNAME: PHONE: CONTRAZA�CTOR'S NAME: LIC NO: 1111 i RUL ill/
' N/C CONTROL#
2 1 CHI'1'ELT/ENGINEER: LIC NO: RE S: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECTM MECH
PERMIT ISSUANCE ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affinn that l am licensed under r JOB DESCRIPTION
C1mZ Y pd Professions
Coer and mmecense with ��T `
ts100 full fonlandvfDivision3 ofthe Business and lsr,fessions Codc,and my license is in PANELS
FC W F full force and effect.
FZW License Class LIC.# UPTO 200 AMPS
m,y Date Contractor. 201-IOW AMPS
ZONti ARCHITECT DECLARATION OVER IOW AMPS SQ,FT.FLOOR AREA $/SQ.FT.
CZ O I understand my plans shall be used as public records.
fir.L E; SIGNS ELECTRICAL Ie�
`meq` G] Licensed Prafeastanal I A E
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W!:JF 1 hereby affirm that I am exempt from the Contractors License Law for the
'�,Qm following mason.(Section003LS,Business and Profession&Code:Any city orearmay 'TEMP.METER OR POLE INST. p (� (#�� f t
NCOy j which requires a permit to construct,alter,improve,demolish,or repair any stmeture p�/ Ell
priorto its issuance,also mgoires the applicant forsueh permits fineasignedsmtement POWER DEVICES M L. J
that he is license) 1
SµGC with
Section
..Division the Commemr&License Lew(Chude) SWIMMING POOL ELECTRIC
X� 9(commencing with Section 90W)Of Division3of the Business and Pml'essions Code) LUATION
W�,� or that he is exempt Imminent and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-
9ution 9031.5 by any upp�l�ant far a,omit subjects the applicnnuo a civil wholly of FIXTURES
not mora than five hundreddol lars(SSW).m NEW RESIDENTIAL ELECfR 5 Ff.❑ LaeownerofHapmPerry,ormy employceswiP wagesnsiheirsolecompensetion, Q' STORIES TYPE CONSTRUCTION
d3— will do the work,and the structure is not intendedorofferedforsWe(Sec.904W,Business
and Professions Code:The Cmillmor's License Law does not apply to an owner of
,,.perry who bit Ids or i,.proves thereon,and who does such work himself.,linchpins
own employces,provided Pat such improvemen[sare not intendedoroffemd forsale.If, -----OCC.GROUP HES.UNITS
however,the building orimpmvement is sold within ane yeafofcomploma,[henna, TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthe property,am exclusiveiyctmtracting with licensed comocton to QTY. PLUMBING PERMIT FEE FLOODZONE APN
consumer the project(Sec.9044,Business and P,.fmsmas Cade:)The Contractor's 1 PERMIT ISSUANCE
License Law does not apply to an owner ofpropeny who builds or improves thereon,andits
who contracts forsuchproje as with acontmetor(s)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 om exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT:DEVICE OUTSIDE.FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATIONDECLARATION SCHOOLTAX Y N
❑ Ihertby affirm[he[IM1aveawrtifioate of consenlmself-Insure,ora nerd Beam of PIX'NRE9-PER TRAP —� RECEIPT#
Workers'C,mpcoca[ibnlmommeeoracenifiedwpythereof(Sec.38W,Leb CJ which PARK FEE Y N
re all employee's under this Penni[. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA)
Wiled copy is hereby famished. PLANCIIGCK FEE
Certified copy is riled with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompletnd Pike permit is frcho hundred dollars S 10H SEWER-SANITARY-STORM EA.200FT. ENERGY HE
m less)
Ia,mify that in the peltnmarroeofthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELECI'R
not employ any person in any manner so m to become subject to the WorkersPAID
o z CCma,.anion Lawsaf California. Doc ATER SY EM/IREATING Date Receipt#
Applicant
0 NOTICE TO APPLICANT:If,after making this Certificates of Exemption,you should NEW RESIDENTIAL PLUL SQ,FT. TOTAL:
become subject m the Worker's Compensation provisions of the Labor Code,you must
[�^ forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z I hereby affirm that hem is a construction lending agency for the performance of
U C) the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
H Lender's Name
0 F tenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have read this application and state that the above information is
c rowL Iagrmfoemmply whballcityandaoumy ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
i building construction,and hereby authorize representatives ofthis city[center upon the
U Z above-mentioned propeny for inspection purfroses. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree 10 save,indemnify and keep harmless the City of Catarina,against
liebili[ics,judgments,ws[a an expenses whi n any way accrue against said City AIR HANDLING UNIT(TO 10,Wa CFM)
tnconseque sof gran' exflitpel
AIR HANDLING UNIT(OVER 10,000 CFM)
Si It fApplicant/Cmansamr Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('1'O I00,00013'fU) Date Receipt#
Will the applicant or future building occupant sumer handle hazardous maternal
as dented by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety HEATING UNIT(OVER[100,000 BTU) L;
Code,Section 25532(a)P
❑Yea 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR IW,000 BTU) ISS NCF,pATE
Will the eexaminationst or ure defined by H e ay equipment Quality Management ant Q" I �✓
arardous air comamlmms ae defined by He Bey Arca Air Quality Management BOILER-COME(OVER 100,0(10 BTU)
e
isuicR DECR J
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.FT. Hv 1992
1 have read the hazardous materials fequinchems under Chapter 6.95 of the
Cal
fthe uiaingdoes Safety
entlyhvea c count,
is my nd
Iundenotiftand that Clic V� i,RUI'G1v
if the building docs not currently have a tenant,that it is my respmsibihry to ratify the
occupant of the mqulremen¢which must be met prior to issuance of a Certificate of
OccuPwcy. .
Owner or euPonzed agent Date TOTAL: ISSUED B
OFFICE