24866 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
NO-ELECI RICALPERMIT N
BUILDING PROJECTFEESnFTCA'f10N O. 24866
CITY
VwlCITY OF CUPERTINO PLUMBwc-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT
BUILDING ADDRESS: SANITARY NO. APPLICAJ'ION SUBMITTAL DATE:
1� UNI'fN LOT#
\ I :RS NAME: Y s.L -O PHONE: ^� C ACfOR' NAM s: ^ LIC NO: [
l x oV Y N/C CONTROLp
VtCI1171CfBNGI EER: LIC NO:' ADDRY S: - ❑ -
_ { Q
Tf PHONE. BUILDING PERMIT'INFO
�^GGNTACQTY. EI,IiC'I'I2IC PERMIT r FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE - 0 ❑ YPI El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyz, I herebyaffirm that l an licensed under provisionsofaidner9(commencingwith
R
RUE
fall
orce and)e f Division 3 of me Business and Professions Cale,and my license is in PANELS ��
ech� full License
Clndeffect. �_J 111 ku•,
Qyt� License Class Cu.p UP T021u)AMPS
yQyDate Conwmor 201-I"AMPS � '
2.Oli!-1 ARCHITECTS DECLARATION OVER IM AMPS SQ.PI'.FLOOR AREA $/SQ.IT.
oz— 1 understand my plans shall be used as public records.
F o,iJ SIGNS ELECTRICAL
Qy�„3 Licensed Pmfeuionnl
OWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC.
Oap. 1 hereby affirm that 1 an exempt from the Contradols License Law for the
'
N31<m following Mason.(Seclion 7031.5,Business and Professions Code:Any city or county TEMP.MMERORPOLHINST,
kE�0g which requires aperatittoconswct.alier;improve,demolish,nrrepair any stmelare
yY to its issuance,alsorc restheu liwm forsuch rmino fileasi dsurtment POWER DEVICES
tt�� prior qui pp pe gne
REjKOpK that he is licensed pursmmmthe provisions of the Conlfacm/s License Low(Chapter SWIMMING POOL ELECTRICall
2.0 9Nommcating with Section 7000)of Division 3ofihe Business end Professions Code) ON
y�Mso or that he is exempt herefrom and the basis far the alleged exemption.Any violation of 0 u
3G Section 7031.5 Is any applicant for a permit subjects the npplicanno a civil penalty of OUTLETS-SWITCHES-FIXTURES t--�
no more than five hundred dollars 1$500} t t-�-1 I
to ❑.I,vsownernfihe xn NEW RF.SIDIiM'IAL CLECTR _SQ. v I� ) "10 i 1 PH CONSTRUCTION
W prre y,or S500Lnyecs wimwagesastheirsolecompenwtion,
a will do the work,and lostractumisnot intended croffefed torsade(Sec.7(H4,Businees /� ��
and Professiem Civic:The Contractors License Lew alas na apply m sa owntt of ex is
property whnhuildsor improves therum,and whodocs such work himselferthrcugh his DATE -
own employees,provided that suchimprovememsaunotimendedoroffereciforsde.If. OCC.GROUP RFS.UNITS
however,me building or improvement is sold withinoneyesrofcompletum,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
cam.). Q-I'Y, PLUMBING PERMIT FET? FLOOD ZONE APN
❑ I,as he I...set er.7ty,mnexclus. oil Prtficasi s CmicensWcommemrem
License
he does
not(Sec.oaro nerodp and Professions Code)Tic Contractor's
Lirorne Law does not apply toenownernfpropeny whobuilds orimpnrv<s thereon,and PERMIT ISSUANCE! � UQ
who contracts forsuch pmjaH with acommctndid licensed pursuant to the Contractors ALTER-DRAIN&VENT-WATER(IA)
Lictme,I.W. FEE SUMMARY
rrs - ❑ I am exempt under Ser. ,B&P C for this rcnson BACK FLAW PROTECT.DEVICE OEM SIDE SANITARY N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ Iberehy afOrm lhmlhinaacudilicum of ammcnum eel6lnsure,oracm4ificnm of
FIXTURES-PER
'1'RAP RECEIPT#
Wofkem-Cirmpnmmionlnsuranceoracenificdcopythereof(Sec.3Nm,lxb CJwhich PARK FER .Y N
exes.WI employee's under this p.il GAS-EA.SYSTEM-1 INC.4 OUTLEEIS RECEIPT#
Put icy# �• �D BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 41EA) PLANCHECK FIE
❑ Certified copy is hereby fumixhed.
❑ Certified copy is filed with the city inspection division. GREASEIINDUS'TRL WASTE INTERCHPTOR GRADING FIC
CER'T'IFICATE OF EXEMPT ION PROM WORKERS GREASE'IRAP SOILS FI713
COMPENSATION INSURANCE
(Thissectim need not be completed ifthe permit is(mons hundred dollars($I00) SEWER-SANITARY w STORM EA.20017. ENERGY FBE
oless.)
I certify that in the Performance of the work for which this permit is issued,I shall WATER HEATER WATNT/ELEM
nor employ any Penn in any canner so as to become subject to the Workers' PAID
Cumpematimr Lmssof Celifomia.Date WATF.RSYSTEMPRF.ATING Date a
Reipt#
Q 7-+ AFFlicanr
NOTICE TO APPLICANT:IL after mukin this Certificate of Exemption.you should NEW RESIDEISO1AL PLMB. SQ.Ff.
g P TOTAL:
V)
becameSubjectwary the Worker's Coons orttinnpmvit shall I the Luba Code,you mon
a ? I'onbwith comply with such provisions or this tarmit shell be deemed revoked. BUILDING FEF:
0. Q CONSTRUCTION LENDING AGENCY SEISMICF:,
Z 1 hereby affirn that them is a construction lending agency for performance of
L) Q the work for whichthis Form,is issued(Sao.3097,Civ.C.) 'TOTAL: .OQ ELECTRICFEE
Lenti is Name
rr PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE D�
V 1 cenify mut I have read this application vad state that the above information is
Fa eonem.l agree In comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEF.
_ IA building construction,and hereby authorise representatives ofthiscity,to enter upon the CONSTRUCTION TAX
L) Z ahnve-memioned property for inspection puBnses. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Ijahilitic,judgmenta,cnsn and expenses which may in any wayacenta against said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of the grunting of mix pemtit.
I - AIR HANDLINGUNI'r(OVER I O,OW CPM)
Signature of Applicam/Cmememr Data HXI IAUST HOOD(W/D UCD PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(DO I00.0d)BTU) Dom Receipt#
Will the applicant or future building occupant store or handle hvrvdous material HEATING UNIT(OVER Im,0009TU) TOTAL: �OQ
as defined by the Cupenim,Municipal Code,Chapter 9.12,and the Health and Safety
Collo,Satlon 23512(a)
❑Yes VENTILATION FAN(SINGLE BESIDE`J�No
u heart oorl'mure buildin HOILER-COMP 0HP OR Immo B'I'U) ISSUANCE DATE
Writhe
pp grmcupam useequipmem ufdevicee which emit p
hazwdous air comm�tinvnts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,070 BTU) PAID
D
District? I \1 '
❑Yes )l No NEW RESIDLNTIALMECH. SQ.PI'.
1 have read the hamorkmous materials requirements under Chapter 6.95 of the MAR 15 1993
California Hoalth&Safety Code,Semi x25505.25533 end25534. 1 undevmnddid
ifmc buildingdncs not mrncntly hnv sere tad,Ihat itismyfespnnsih'lity mnotifythe i
cupahtof ralt'r encs whic must met prior to mance rifieme
Occnpaney fCIII Or vUrrh I 114
Ow r thoriuJ vgem a Dat TO PAL: ISSUED By: C
OFFICE