24486 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-hLRU I HICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24486
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
NlllI d 'S01IING ^I Ver—��� ,x, f �INI`. ./1,.� LOT# SANITARY NO. A�LICA=�SURMITTAI,DATG .
OWNERSNAMEE. r(�/ PHONE: /1.11 CCIO•NNTTRAACCTOR'S NAME: LIC NO: N/C CONTROL#
Visvl -732-13
•ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING'PERMIT INFO
ELECTRIC PERMIT FEE
BLDG ELECT 1M0 MF.CH
PERMIT ISSUANCE 0 El ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Gf6Z I harebyaffrmtbat l ant licensed underprtvisionstfChapter9(commencing with LOB DESCRIPTION
W40O Section 9000)nf Division 3 of the Basins.and Profestatns Code,and my license is in PANELS
full game and
License
Claseffect UP TO 200 AMPS `
dF y License Class Lia#
m d Date Contractor 201-1000 AMPS
ZFO vwiZ ARCHTI'ECrSDECIARATION OVER 1000 AMPS SQ.FI'.FLOOR AREA $/SQ.1T.
O Z—M 1 understand my plans shall be used as public records.
Fen ca� SIGNS ELECTRICAL� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�mm�44OLF I hereby alfirm that I am exempt from the Commences License Law for the
W 3 a m following reason.(Section 9031.5,Business and Professions Code:Any city Carmody TEMP.METER OR FULL INST.
F,I+j06 which requires aPermit no coast ruct,Cho,improve,demolish,mrepair any,on'trer°Y prior to its issuance,also requires the applicant for such permit o file a signed stvtemen[ POWER DEVICES
fy OOC that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter SWIMMING FOOL ELECTRIC
Gm�4 9(commction,with Section]000)of DMsion 3ofnim Busrestatd Professions Cade) VALUATION
❑y or Wat he is exempt therefrom and the basis for the alleged exemption.Any violation of
�yQ
Section 7031.5 by anyapplicam for a permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
not ro thunfivehundred dollars($500). NEW R[SIDENTIAL 6LECTR _SQ.kTI'.
K m h scum .fnhepraperty,ormyemployeeswith wages us nheirsolecompens.Iicn. STORIES 'TYPE CONSTRUCTION
a3— the work,and Ole stramum is not Intended proffered fersale(Sea'JM4,Business
d Profosslons Code:The Contractor's License Law does not apply no an owner of
propcny whebuildsarargamses(larmommalwho date,such wCalbireelfathrough his - - OCC GROUP RES.UNITS
con employees,providedchat such improvements are not intended oroffned forsnle.If,
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale).
)1.as owner Child property,am exclusively contracting with licensed contractors to QTY. F ,r.FLUMR[NG PERMIT PEE FLOOD ZONE APE
❑
onstruct the project(Sea 7044,Business and Professions Code:)The Contractors
Licansel.awdocs�otapplytoanownerofpropernywhobuildsorimprovesfhereon,and PERMIT ISSUANCE
who contracts for such projects with a contrvetods)licensed pursuant o the Contractors ALTER-DRAIN&VENT WATER(6A)
Liccme Law. FEE SUMMARY
❑ I van exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
• Owner Date RECEIPf#
GOND
AREA
ROOF, , .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCf1O0L TAX YN
❑Workers
Co affirminInsurnce ortacemeof consent to pytherolf-in 3800,Lab C.)while of RECEIPT#
FIXTURES-PER TRAP
Workery CompensntionlnaumncetraccrtifiaA copy[hcraof(Sev.3800,Lab C.)which - PARK PP.E YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ CertifiedwpyiNherehyfumished.
❑ Certified copy is filed with the city inspection division. GREASUINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200 P. ENERGY PEE
or less.)
IceMty that is 11.N,fnaranceofthe work farwhichfins permit is Issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compmadion Lawsof Calimson. Date WATER SYSTEMITREATING Date Receipt#
O 7. Applicant
z 0 NOTICE TO APPLICANT:If.after trakingdox Certificate of Exemption,ymithould NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
L' gA become subject the Worker a Compensation provisions ofthe Labor Code,you must
�i forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
rrC�� I hereby affirm that Nem is a construction lending agency for the performance of
U O the wark for which this permit is issued(Sec.3099,Civ.C.) O ELECTRIC FEE
H
Lender s Namea` ' PLUMBING PEE
O F
Under,Add....s QTY: * "MR_GI9AMCA4 PERMIT FEE
U 1 ((y that l have reed all
s ity and county
and slate that
ces airs above information relat MECHANICAL FEE
i- cornet.construct comply herebylctynnd ceuntytMtives of and state laws the PERMIT ISSUANCE. ��
U Z marvebuildinn construction,Omand hereby mr,preaentatives of'his shy to enter upon the CONSTRUCTION TAX
uhov(We)agree) indemnify
and ALTER OR ADD TO MECII.
U � property p pnme,sea. -
(We)agree ru save,indemnify and keep harmless the City Caped,, Cit
liabilinies,judnmmnst
es,csannse
Card exptswhich mayinany way accrer ueagainsn saidid City AIR HANDLING UNIT(TO IO,OIXI Cl
in can once of the grunting this perm.
AIR HANDLING,UNIT(OVER Ig000 CFM)
1-7
�nan f p IicanV nn rattan Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.08)BTU) - Date Receipt#
\ ' the applicant or future building occC,Cn,sore or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL,:
as defined by fire Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Cada,Semina 25532(e)'1
11 Yes ❑Na VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will Ile nppomar nit,as building bocupanBayaequipmenmrdevioes which earn -
hazardous air contaminants as defined by the Bay A.Air Quality Management BOILER-COMP(OVER 100J100 RTU) w A P
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. AIO 7
I have rend the hazardous materials requirementsNov under Chapter 6.95 of the v 1 � �n
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that C11 Y Ur J
if the building does not currently have a tenant.than it is my responsibility to notify the LllY
I
occupant of the requirements which most be mat prior o issuance of a Certifieme of Cri J
Ormpan y. �'''�.� #�t
Owneraro tionamed agent Dote TOTAL: ISSUED BY:
OFFICE