24985 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - -.1111111..'A- PERMIT NO.
111 InNG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24985 A �O C
BUILDING PROJECT IDENTIFlCATION L L' o J
• BUILM)y'G ADDRESS: SANITARY NO, APPLICATION SuRstri I'AI.DATE
6dk%rAEI 41 -SSU UNIT is LOT#
OWNERS NAME: C PHONE: CONTRACTOR'SNA LIC NO:
WG CONTROL#
IRCHITECT/EhIGINL'ER: LIC NO: ADDRESS: ❑
CONTACT: Pxorve: r e ' 3^<` r BUILDINGPERMIT INPO
QTtY, ;GeJ ,j EFECTRIC PERMIT. „FEE
BLDG ELECT PLUMB MIiCH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Owz Ibereby affirm that l am licensed under provisionso'Chaper9(commencingwith
POO❑ Section 700(1)of Division 3 ofthc Businessland Professions Cod,end my license is in PANELS
C U U full force and effect. 11
FZ' License Class I# UPTO200AMPS
rn 6 y Date Conuaanr 201-104 AMPS '
F'- ARCHITECTS DECLARATION 11 r�.$Dml>IpTLC> REA $(SV.IT.
OVER 1000AMP$ !!I Ili IL'
G 1 undccstund my plans shall be used ns publi<recosds. 0 !tet
F'4L y SIGNS ELECTRICAL
gg�4
Licensed Professional OWNER-BUILDER DECLARA'T'ION SPECIAL CIRCUTWMISC.
�Dx4'OaF 1 hereby uffrm that I am exempt from the Contractor's License Law for the
W 3 Oco following ream..(Secd.n 0031.5,Business and Professions Cede:Any city or county TEMP.METER OR POLE MST.
y which requires a permit to construct,start,improve,demolish,or repair any suuctum PATH
I in its iwounc,alnorequlres their'licant fnrsucM1 permivolilensigneJ xtnmmem POWER DEVICES
w p Oz that he is licensed pursuem to the provisions of the Conuactoi s License Law(Chapter
e.xdov. 9(commencing with Section 7")of Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALU/A�T1
W gra or that he is exempt herefrom and the basis for the alleged exemption.Any violaaimilf OUTLETS-SWITCHES-FIXTURES
kZa Section 7031.56yxnyupplicxntl'otapermit subjects the.pplicanuo a civil penally of eO ��
� O t than five hundred dollars($500). NEW RESIDENTIAL ELELTR S FT.
W 1.=erofthepmpeny,ormyemploywswithwagesastheirsolecompemafion, Q' STORIES TYPE CONS)RUCTION
a will the work,andthc svucare is not intended nroffcred f.rnalc(See 7044.Business
and Professions Code:The Commetor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselforahrough his
own employees,provided that such improvemeatswenot intendedoroffcied forsale.If. OCC.GROUP RES.UNITS
however,the hu ningor improvement is sold within one year ofcnmpletion,thcowner- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
❑ Las ownerofthe property,am exclusively contracting with licensed comincaora to -{* PLUMHING,PERMIT FEE FLOOD ZONE APN'
msuuct the project(Sec.7044,Business and Professions Code)The Contractors
License Lawdeas not applyto anownerofpropeny who builds or improves income and PERMIT ISSUANCE
whoc.ntmcts fors.ch projects wima contmetogs)licensed pursusnun Ne Contmemrs ALTER-DRAIN&VIiNT-WA'I'LR(EAG License Low. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE TSD P.ES
Dam
Owner
SANITARY Y N
RECFIPI'p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDF.CLARATION SCHOOLTAX Y N
l 1 hertby affirm that have n unificate of ronsem m ulf-insurt.ora certificate of RECHIPT Is
•mkas'ComPrnsation lnsumn¢or a cenificd copy thereof(Sec.3800,Lab C.)which Fl%TURES-PER TRAP PARK FEE Y N_
�...mrs all cmpl.yee's under this pertain. CAS-G.SYSTF,M-I INC.400fLET5 RF.CIBFT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GRPASFANDUSTRL WASTE INTERCEMOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(ThisneationneeJ not becompleted ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees.)
T certify that in the performance of the walk far which this permit is issued,l shall WATER HEATER WM'NT/ELECTR
not employ any person in any manner sur as in became subject to the Workers' PAID
z Compea,mi.n Lawsof Califomiu. Dam WATERSYSTEM?BEATINGDae Receipt If
Applicant
0 NOTICE TO APPLICANT:IL after making this Ornificae of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT.F TOTAL:` become subject to the Workers Compensation provisions of the Labor Code,you must
� > forthwith comply with such previsions or this pemdt shall be deemed revoked. BUILDING FEE �a
0.W1 [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z Ihembyaflinn thanhere is a cmearectom lending agency for the performanx.1' TOTAL: ELECTRIC FEE
the work for which this permit is issued(Sec.3097,Civ CJ
I<ndees Name o m PLUMBING FEE
O F lenders Address QTfY.'rf €`X Ml Cf1ANICAISPERMIT 'rs, rP.EC
G 1.Indy t In
1 have read this city
and
and state that the above information rmaan is " ' ° MECHANICAL.FEE
F conengeonsamwmply with
yandyaad county oNtives osaad nae lower upon
gle PERMITISSUANCE
y buioo-amnmocalioqund hereby itor..representatives ofttdscity toenmr upon the CONSTRUCTIONTAX
L) ehnvewe)igree pmpve,ind inspection purposes. AL'I'L'R OR ADD TO MECH.
(We)agree to save,indemnify and keep hamle a City of Cupertino against
liabilities,jud emerandespen. whichmay' enywayacerueagat Urald Ciry AIR IIANDLING UNIT(TO 10,000 CFM)
in consequ .of a granting oft '. omit.
V w AIR HANDLING UNIT(OVER 101,000 CFM)
Will pi nVContmctor eDate EXt1AUST HOOD(WMUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNP(TO 100,000 BTU) Date Receipt#
Will the upplicaw or future building occupant store or handle hazardous material
m HEATING UNIT(OVER 14,0(0 BTU) lY)TAL:
defined by the Cupertino Municipal Cad,Chapter 9.12,and the I Icahh and Safety
Calc,Section 25532(x)'1
❑Yes 11 No VENTILATION VAN(SINGLE NESID)
Will thee licant nrfumrcbuildin aurae BOILER-COMP(JHPOR 100,411 RTU)
ISSUANCEDATE
pp gwcupan yuipmemurdevices which emit
�omr air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.PT.
PAID
I have read the hazardous amends requirements under Chapter 6.95 of the n�
California Health&Safety Code.S«tions 25505,25533 and 25534. 1 understand that APR 0
if Nenant
e building does not currently have u t ,that it is my responsibi lay to notify the 1993 P)
ocenpnnt of the rcquimmema which rant be mot pole,to ismaare ol'.Crinfle a of r7��-/��x,`[Jg�J��'�,
\ Ownerooauthmized ugetn Date 'TOTAL: ISSUED BY: