24968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINOB ILDI .-ELECTRl AL PERMI'TNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24968
� a14 J o O n C O
BUILDING DIVISION BUILDING PROJECT IDE.N'FIP'ICATION L
BUILDING ADDRESS: I —7'7
] 60l J I_ ST - SANITARY NO. APPLICATIONSUUB_M_f(IT] DDATDATE.�I''
k o rb❑`Dl�l 0— UNIT# LOT lio.I �•�1
�..:'• NIiRS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CON'1'ROLN
D &,oat zy- .(3642230
-RFit'IEC INGINEER: LIC NO: ADDRESS:
17 W•Y1'j'A✓F_. afieoCA100El
'ONTACE: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L ELk PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
p C 2 I hereby affirm that l um licensed under provisionsofChapter9(commencing with JOB DESCRIPTION
WOO Section]000)of Division J of be Business and Professions Cade,and my license is in PANELS
yVtfull force and effect 8 \ C `��
FZW License CVaz .�Lie.N `q22 0 UPTO200AMPS Jv
vi 6y Dam ��_J- ��_Canuacmr 'V rTAJ 1, 201-1000 AMPS
F^ri>r% ARCODECJ-SDECLA ATI SQ.FT.FLOOR AREA fuliq FT.
Cz Iunderstad lune♦ Javp bhe rec • OVER I0f1U AMPS
OL p
�,In F_ul n � SIGNS ELECTRICAL
��s� LlccneJP�f s nal
1XOWU OWNER-BUILDER DECLARATION SPF,CIAI.CIRCUIT/MISC.
K06F 1 hereby affirm that I an exempt from the Contractor's License Law for the
W 3 U.F- following rtason.(Section]031.5,Business and Professions Code:Any city or county TLMP.METER OR POLE INST.
O Q which squires n permit 1.ennwa.alar,improve,demolish,or repair any strucmm
CW}:; prior to its issuance,also reyuims the applicant for such permit to file a signed statement POWER DEVICES
W M p0 that he is licensed pursuant to the Provisions of ,Commctors License Law(Chapter
d Ke� 9(commencing with Section'l000)of Division J ofine Business and Professions Civic) SWIMMING POOL ELECTRIC od C/VALUA'jJwy��
rJ.
W:2, nr that he is exempt mcrefrmn and the basis for the alleged exemption.Any viNmion of OU'1'LISTS-SWITCHES-[S
FES Q SZ 4 Section 9031.5 by any aephout for u permit subjects the oppllranuo a civil pcnuhy o[ (J `X f
xx out more then E0).Five hundred dollars(550
a'Fo [II,asownerofthepropeny,ormyemployeeswithwagesastheirsolecompenation. NEW RfSIDLNTIAL ELECTR —SQ.FT. STORIES TYPE CONSTRUCTION
a3=a willdo thework,nna the stmnuafirm,moubledonoffcred for ade(See AB14,Business
and Professions Code:The Conmamors License Law does not apply to an owner of
property who builds or improves daemon,and who does such work himulfor through his
nemployees,providW that such improvements semen inhndedoro(fend for sale.If, OCCGROUP ® ' E .UNITS
however,the buildingto improvement is sold within one yearn(completion,theowner- TA A
builder will have the burden of proving that he did not build or improve for purpose of �A I1�
sale.). TY. PLUMBING PERMIT FEE - �1 FL00 'e�N tqPN
❑ Loa the Protect
me propSec.70,am Business
oil contracting with C rle:)sed The immuch is Q -� ���1 �
Lmenet me project pply n an o Business ata Professions Code)The Conrmctadd 1
icense Law does not upplpotn ownerof propcny whobuildsaimpmvesncereon,and PERMIT ISSUANCE
whence Law,forsuch prnjuts wiN aconvacmrts)1icenxd punuanuorhe Commaors
License Law, ALTER-DRAIN&VENT-WATER(G)
t MATF
❑ 1 am exempt under Su. ,B&P C for this rtnson BACK ROW PROTECT.DEVICE OUTSIDE FEES
JLV,1
NITARY YN
Owner Dare DRAINS-Iq.00R,ROOF, COND. of ELPEp
WORKMAN COMPENSATION DECLARATION HOOLTAX Y
❑ Thereby affirm mmlhnveacenifcam nfrnmem aselGinsure,ora cenificme of FIXTURCS-PF.R TRAP RECEIPI'a
Wortrrs'Compcnsution lnsumna oracenifieJ Copy thertof(Su.3800,Ia60)which RK FEE YN
ars all employee'.undenhis ermir. RECF,IPI'#
Policy 102 O GAS-EA.SYSTFM-I INC.40UTLEfS
Co any O•YI.Q BUILDING DIVISION FEES
enifieJ copy is hereby famished. GAS-FA.SYSTEMOVER4(EA) CHECK PERCenifiea copy is fled with the city inspection division. GREASEnNDUSTRL WASTE INTERCEPTORADING DiECF,RTIFICA9'Li OF EXEMPTION FROM WORKERS' GRIiASIi TRAPILS PF.Ii
COMPENSATION INSURANCE.
(This section need no,bit,rompleted fate permit is!onion hundred drift.(1400) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work(or which this permit is issued.I shall WATER HEATER WIVENTIELECfR
\ not employ any penin in any mender so az m become subject a the Workers' PAID
z Compensaionlswsnf Califontia. Date WATER SYSTEM/TREATING
Applicant Data Rueiptp
O
z 2 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESI DENTIAL PLMB. SQ.FT. TOTAL:
Pq become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provision,orrhis permit xhrilI In,deemed revoked. IPAI
G ITE I
CONSTRUCTION LENDING AGENCY FEE 1
Z I hereby affirm that them is a construction lending agency for Ne perfommnce of
V 0
the work for which this permit is issued(See3097.Cie C.) TOTAL: C FEE
1<radic Name
o U 1<nderc Address QTY. MECHANICALPFRMIT FEE NG FEE
I certify that 1 have read this application and state that the above mmrnaean is
L1s urrect. Iagreemenmplywimallntyendcounty ordinances and state laws rclaling to PERMIT ISSUANCE ICAL FIiE
fn building comnuction,and hereby aumoriee representatives ofthis city m enter upon the
V Z abwc-mentioned property for inspection purpwes. ACI'ER OR ADD TO MECII. UCTION TAX
(We)agree m save,indemnify and keep marine,me City of Cupertino agnlnst
liabilities.judgmcros,cnsb nndespenus which may in any way me against said City AIR HANDLING UNIT(1010,000 CFM)
incon.Fterse egranringo thitpetmit.
lP yi3. AIR HANDLING UNIT(OVER I O,OW CEM)
fi re of Applicam7Contocmr Dole EXHAUST HOOD(W/DUCI]
I IAZARDOUS MATERIALS DISCLOSURE If EATING UNIT TO 100,0(10 RTU) Dec Receipt#
Will the applicant or future building ocermnm store or handle hazardous material
vs
defined by the Calcium Municipal Cale,Chapter 9.12,and me Health wJ Safety HEATING UNIT(OVER 100,0)0 BTU) T
Calc,Section 25532(e)9
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
3HP OR 100.000 BTU
BOILER-COMP ISSUANCE DATE
• Will meapplicanmrfuture buildingoccupam uuequipmemordeviceswhich emit ( )
,harardons atr contaminants it,defined by me Bay Area Air Quality Management BOILER-COMP
District] (OVER 100.000 BTU7 #-k
a.if,YJ ❑Yea 11 No NEW RIiS1UliNTlg1,MECH.—SQ.FT, r " I D
1 have read the hamNous materials requirements under Chapter 6.95 of the ApR 2 0
Culiforda Health&Safety Cade,Section 25505.25533 and 25534. 1 understand mm
if me building does nor currently have a anent that it is my responsibility to notify the
aecupam of the requirements which must be met prior to issuance of a CeMficae of
Occupancy. CI I Y L)f eo
owner or amhomcd agent Date
TOTAL: ISSUED BY:
Q