24834 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL PERMH'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJKC I EVENT IF'ICAT'IfIN
BUIL LNG ADDR/lES�S: /1-y. y��� SANITARY NO. �APPWCAIION SUBMfITAL DATE
20 LAW ( 1 UNIT# LOT
OWNERS/yy,'AMEl: PHONE: CONTRACTOR'S NAM[: LC •/
l..IA.AV L VV V fn PV'(xf Nle coNTROOLL#
ARCHITF,CIiF.NGINF.ER. LIC NO: ASS:_
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT .,
PERMIT ISSUANCE
LICENSED CONTRACfOR'SDF,CIARATION APPLIANCES-RESIDENTIAL +' „OJpBDFSCR OfJ _
PCZ IhercbyaffrLICENSEDiCONT under#rotisDECL RAT( 9(cammencingwiN
WO 0 Section]000)of Division 3.f the Business and Professions Cade,and my license is in PANELS
yd{"; Poll leave and effect. nn
<, Li Class�Lic.a `$3 UPT0200AMPS
y< ate�L�Contmcwr 201-1000 AMPS
F yZ �7--1 ARCHITECTS DE ARATION SQ.fT.FLOOR AREA $/SQ.FT.
ZOrn— SIGN IEOOAMPS
O z—rJ I understand my plans shall he used as public records.
F,wF; / SIGNS F.LE
Q�Y�„J fa'cenu P�'rofcssinnul
y W U but I a.-B exempt
I,.theDECORATION SPECIAL C CUI /h IS
XOa0 1 hereby off Ihm 1 am exempt from Nc Comonors License Law for the a
mi+ati following rcusnm(Section]03 L5.Business and Professions Code:Any city or county TEMP.MEkAgUAg�,AE
< which requires a pormit m tom ottel.altar,impmvc,demolish,or repair any smictore
priorm its issuance,also requires the applicant for such permit file a signed sumemert POWER D8V1 5
tyC�0z that he is licensed Pprompt to the provisions of the Contractor's License Law(Chapmr SWI NG POOL FL a.nCFLL 9(composite g with Section 71X10)of Division 3rf the Business and Professions Code) :faa� VALUATION
� OF
_¢ or he is cxcmpuhendir mond the basis for the of le,ul exemption.Anyviolntlnn of
Y Section]03 L56 an I' Ifura a Isuh' t thea I' moa civil tr f OUTLETS-.SWITCH) -PIXTIIRLS lJ
FrZ Y' Ydoo Iwo p rml Ices pp Icon Penn ya
not more than Ove M1undrcd Aollars($5001.
�=L1 NF.W RFSIDBN'I'IAL ELECI'R .IN'. STOR ;S TYPE.CONSTRUCTION
CFS ❑ Laserock,f Ncp,routuonnyempluyed oroftend for sale(Sec.
044,Bsiness
will dr Nework,awd Neshu,mmisnot is Deese La creoespolpply to an Business /
and Profen s Cndo:The Contractors License Lnw Anes not apply to u of
property who builds or improves thereon,and whodues such work bimsclfordon.gh his -
em,tolnNw
yc .pruv ided wch impmvemems ammt'mtcndWnfufl'eredfarmle.If, GC.GROGP RES.UNITS
however,the building or Improvement Is sold within one year of completion,the owner- .m
builder will have the burden of proving that he did nm build or improve for purpose of
We.).
❑ Las oraernf Ne pp,wo ,amexclusi,ely comractiog with licensed contractors to QTY. PLUMBING PERMIT FEE MOOD ZONE APN
- commit, he project(Sce.7044,Bmiocss uwd Professions Csdu)Tt,e Curvatures
License Law dossers apply to an ownerofproperty whobuilds or improves thereon.and PF,RMITISSUANCti
who contracts forsuch projects with acumacturist licensed punmento the Committees 1 gLTF,R-DRAIN&VENT-WATER EA
License law. 1 > �. FEE SUMMARY
❑ 1 am exempt under Scc. B&P C for Nis mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT N
DRAINS-FLOOR,ROOF,AREA,COND.
Its WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
'E7 I hereby affirm that l have a certificate ofconscnuosclf-insure.or a certificate ofFIXTURES-PER TRAP RECEIPT
-Workers C,mpcnsmivn lnsuaancc ore certified copy Nereof(Sce.3800,Led C)which r PARK FEE Y N
ti (f:irven all employee's un der this Permit. GAS-EA.SYSTEM-1 INCA OUTLT'S RECEIPI'p
'Policy k BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished. 71
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING IEE ��
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE �d
COMPENSATION INSURANCE
(Thin section need not be completed ifthe permit is for one hundredd,llan($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF, —r
or less.)
I rcnify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENTIELECTR
nm employ any person in arty m as to become subject m the Workers' PAID
Compensation Lawsof Califomia. Date sv WATER SYSTEMfMFATING Date Receipt#
C) z Applicant
Z NOTICE TO APPLICANT:It.after making this Certificate of Exemption,you should NEW RESIDENTIAL PL.MB. SQ.FT. TOTAL:
Ft/) became subject to the Workers Compensation provisions ofthe Labor Code,you must _+
forthwith comply with such provisions or permit shall be deemed revoked. BUILDING FEB O
W SEISMIC FEE
Q CONSTRUCTION LENDING AGENCY
I hereby affirm that(here is r construction lending agency for the performance of
U O the work for whichlnis permit is issued(See 3097.Civ.CJ ELECTRIC FEE �.
Lender's Name I'hUMHING FF,F, �
D" F Lewder s Address QTY. - MECHANICAL PERMIT PEE
U I catty that 1 have read this application and state that the above information is MECHANICAIFEE
s�' W correct. lagree to comply Mil,all city and m inyonimuntin
ces undulate lawsnelsg to PERMIT ISSUANCE �_
holdingt,wstrucdmt,and besebyamouri',e rcprencntulowsofthls city menta upon Ne CONSTRUCTION TAX
U Z above-mantirned property for in,c,lion....muses. ALTER OR ADD TO MUCH
(We)agree 1.oa, ,Indenamly and keep harndce,the City rf Cupcnino against
liabilities,judgmelI tuts and exPre"'whorl, ryin�ny wey u¢rucagainsI said City AIR HANDLING UNIT(TO IQ(IW CFM)
in sequence of gemming of this Knot.
AIR HANDLING UNIT(OVER 1(I,WII GEM)
Sib #pies on moorate EXHAUST HOOD OVMUCp PAID
HAZARDOUS MAI'MEALS DISCLOSURE HEATING ON]F(TO IOH00(1 BTU) Date Receipt#
Will the applicant or future building occomm store or handle hr-r, kus material HEATING UNIT(OVER IOO,IXp BID) TO L:
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(¢)] VENTILATION PAN(SINGLE,RESIDE
❑Yes ❑No
ISSUANCE ATE
Will Neu licamorfmurebtildin cu tusee ' t,rdeviceswhich emit BOILER-COMP(3HPOR I00,000B11i
PP eb pan 4ea Air
h_aNuus air comaminanu as awned by the Bey Arca Air Quality Management BOILERCOWLOVER 100.00p BTU)
Dislriuut
yt� ❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FE P N I D
t
I have mad the laxatives materials requirements under Chapter 695 of Ne
j California Health d Safety Coda.Sections 25505.25533 and 25534. 1 andemand Nat
if the building does not currently have a tenant,that it is my responsibility to notify but MA 93
occupant of the requirements which must be met prior m issuance of a Certificate of
Occupancy. I 1
Owner or authorized agent Date ISSUEDB . < < U_-
OFFICE