24779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCI RICA[. PHRMIPNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n ^ �'](]
BUILDINGPROJEC'I'IDET'I'IE'ICA'f 4 ION L I J
w THAT.JNG AppyliSS:� SANITARY NO. APPLICATIONNSUBBMMTFIIALDATE
(���yy 1L UNIT N LOT 0 Z♦rl[dip
OWNI�RS typplly ^ ^`I CONTRACTOR'S NAME: LIC NO: NC CO`NTRYOL#
ARCHITECPiENGINEER: LIC NO: ADDRESS: El ^,^ 1
CONTACT: PHONE: 'O�O QTY. ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
1.��Cl�' L i C P1 UMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 100 DESCRIPTION
pCZ Ihcrchy nllimnhm lore licensed underpravieiansofCTaper9(commencing with
�alOp❑ 9wtion]INNp of Divixinn3 of the Business and Profeasiuns Coda,and myllcenro is In PANELS
�dE full move send affect, O
<z,m Liccne Clms Lick UP TO 200 AMPS
vFi�y Data Comwcmr 201-1000 AMPS
0Z Cl ARCHITECTS DECLARATION OVER Hill AMPS SQ.IT.FLgDR AREA
O Z_ 1 understanA my plans shall be used as public records.
r-(_W SIGNS ELECTRICAL
KKK,' �J Licensed Profcumord
9KQ OWNCRTUILDF.R DECLARATION SPECIAL CIRCUITIMISC.
0 1 hereby affirm that 1 am exempt from the Contractors License Law for the
R13LLy following rcason.(Seedon]03L5,Business and Professions Code:Anycirymemandy TEMP,METER OR POLE UNIT.
a which requires a permit to construct,after,improve,demolish,or repair any stmaurc
wn>-� PHe,,.as hamnce,.B.reyuires theapplicamtforsucb permit to file.signerlsmemcm POWER DEVICES
P1 K O thin he is licensed Pursuant m the Provisions of the Conhanm's License Law(Chapter
adp� 9(commencing with account 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC a yp1.UA'170N
,that h70315mpnhcan I -end the baspermit
ects the spin
Any viol.tinn of UTLETS-SWITCHES-FIXTURIS
Y Section]o31.5)y any aPPlicum for epemlil subjects the epplicemmecivil penalty of
Cnot more Than Eve hundred Jollara($5011).
o ❑ I,asowneroflheprnpeny,ormyemployeeswithwagnasiheirsolecompenvatinn, NEW RESIDENTIAL ELECR _SQ.FT. STORIES as TYPE CONSTRUCTION
wllldolhewnrk,anA the xlmewreie nmtlmendW orofferedfnrsala(SecA044,Business
and Profc..was Code:1'1his Ciono m a s License Law dries not apply I.m owner of
proponywh..huildsnrin"novesthefaon,and whodres such work hlmschm0noughhlx
If. OCC,GROUP RPS.UNITS
rwnemployecv,pmvlAeJ lM1ot suchimprovementsare notimendeA ornffcreJ fmreule.
how eq the huddingor improvement is sold within one yearofcompleion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
crofthepmpeny,amexclusivelyconmctingwithlicenudcon=tonin QTY. PLUMBING PERMIT FEE FLOODZONE APN
o the project(Sae.Tiluil Business and Professions Cale:)The Comracmrs .0'a"License Lawdoeamm�pplyto anownerofpropenywhobuilNorimprovea lhercmt,und PERMIT ISSUANCE
who contmcta for such projects with a contractor(a)licensed pursusentto the Comm"nrs
License law. ALTER BEAT FEE SUMMARY
❑ BACK FLOW PROTECT.DEVICE OUTSIDE FEF
SANITARY Y N
Owner Dat° GRAINS-FLOOR,ROOF,AREA,COND. RF.CIiIPI'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ thereby affirm thatlhaveacenifcate of consenno ulLinsurt.urn xnificaw of FIXTURES-PER TRAP RECEIP #
Workers'Compensation lnsurence or a carolled copy thercof15a.3RW,lah C.)which PARK FEE Y N
covers all employee',under this penal. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT
Policy# BUILDI G DIVISA FEES
Company GAS-PLA.SYSTEM-OVER 4(EA) NCIILCK ILC O
❑ Certified copy is hereby furnished. 0 Ilk III
❑ CenilicA copy i.0 filed with the city inspection division. GRF.ASF71 S R S ' ?RCI R ADING IEE .�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE T 1iS ILS FEE t O
COMPENSATION INSURANCE:
('1'hie section ne<J not be<umpleled ifthe#.toil is for one hundred dollars($IW) SF;WER-S A -S P .20011 NERG [ r
or less.?
I certify that in the performance of the work for which this permit is issued,l shell WATER HEATDATL2q'UELC
not employ any prison in any manner so as to become subject to the Workers' ID
Compensation Lawsof C.Efomia. Data WATMe SYSTESLTRFATING Doe a
C) Z Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Cenifcate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.Fr. OTAL:
F" V) become sebiza t m the Workers Compensation provision of the labor Code,you must
a 7 forthwith comply withsuch provisions or this permit shall be deemed!revoked. BUILDING FEE. --
Ga. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE O
7 Z I heathy affirm theuherc is a conswc0on lending agency for the perfomwntt of
L) O the work(mr which this permit is issued(Sac.3097,Civ.C.) TA F.LECfRIC FEE
LT. rr Landers Name
� f� Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING � �
L) 1 certify ohm I novitiate!this application and nate that the above information is P-2,16 IsSaaaaaaaa
+>'s L2I core",l agreemaomply with all city and county ordinances and stow laws mlmingm PERMIT ISSUANCE MECHANICAL -iE
F^ huilding mm�0uction,onA hereby authorize mpusen"IivesaOhis city to emero,.the
U Z nMve-mentioned prnpny for inspection purposes. ALT'ERORADDTOMECH. CON," U1NTAX
(We)ogrcc m save,indemnify end keep harmless the City of Cupertino agulnrt
Iiabilitic,,juAgmend,cnnr send expenses which m§Y ny way accrue against said City AIR HANDLING UNIT('T010.000 CPM)
in conscquen sfthe rntingofthiapeipso 1. v AIR HANDLING UNIT(OVER 10,000 CPM)
Siifiduurc fit Applicam/Contmctor Data EXHAUST HOOD(W/)UC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00 BTU) Data Raeipl#
Will the applicant or future building o upant store or handle Transitions material
as defined birds,Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER ITIL0o0 BTU)
Code,Section 25532(0)? VENTILATION FAN(SINGLE RE.SID)
❑Ya ❑No
Will theapplicantofmurc buildingoceupant uueyuipmem odevicnwhichrnoil
BOILER-COMP(3HPOR 100,0001PTU)) ISS NCEDATE
Ask=uses taminan
air conts as defined ter by the Bay AAir Quality Management BOILER-COMP(OVER 100.g))BTU)
iahia?
[D as
❑No NEW RESIDENTIAL MECIL SQ.1rT. P 1)1,
I hove mad do hozm Ins materials reaptifternards under,Chapter 6.95 of the LLY
California Health&Safety Cafe,Sections 25505,25533 and 25534. 1 understand that
Pilot buildrIldoaanal currently have a lammt,that it is my responsibility to notify the APR e
occupant of the requirements which must be met prior to issuance of a Certificate if
• occupancy. .
' ' - lrtfilllIU
Owner or authorized agent Dam 'r0 ISSUED BY:
OFFICE