24705 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO M LYING-ELEUJ RICAL PERMITNO.
PLUMBING-MECIHANI
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJEcTIDENTIFICATION 24705
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMUTAL DATE
N�wEIRS NAME:a�`f/1`J 5� PIIp7N� COINTRACI'OR'S NAME: IOfM IJCNO:
Al Nk WeN GrR —/,Pi N/C CONTROL«
ARCHITECT'/ENGINEER: LIC NO: ADDRESS: ❑
-ONTACr: PHONE: RIJILDING Pf;RMIT INFO
. . QTY. ELECTRIC PERMIT PETE
BLDG ELECT PLUMB M17CH
PERMIT ISSUANCE El '1$ F-1 ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
pysZ I herehyvffimuhat l ant licensed.nderpmvisions of Ch.pter9(commeacing wish JOB DESCRIPTION
Y1000❑ Section 700(frr Division 3ofthe Birinessand Professions Code,and my license is in PANES ��• lC��i{w
FaUIJ mu fore,.ad effect. lvu
FZw Lieense Class Ltd.M UP TO 200 AMPS
y6y Dam Contractor 201-["AMPS
ZOyZ ARCHITEC'T'S DECLARATION OVER 1000AMP5 SQ.FT.FLOOR AREA $/SQ.FI'.
OZ—O
1 understand my plans shall be used as public records.
=Y , SIGNS ELECTRICALa�
_LYaLYa''" J Licensed Professional ■YIL� ' dp
y6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT''/MISC. I L �
O I hereby affirm has 1 nm exempt from the Contractor's License Lew firms, "r
W3ay following reason.Ileddrn9113L5,Business and professions Code:Any city or county TEMP.MET ER OR POLE INST. 1t`�� �I 11 t
I"�0g which requires a permit m cunsruct.after,improve.demolish,or repair any smdure s W/
prior to its isarmedalsora,ims she applicant for such perminn file.signedslatemeat POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter
ddoLL 9(commencing with Section 7")of Division 3 of he Business and Professions Code) SWIMMING POOL ELECTRIC iz s AT N
mthm hciscxcmpt Nerefrnm and the hats for the alleged exemption.Any vielmtion of OUTLETS-SWI'fC11[S-FIJ(TURES
tZG Section]031.56yvnyapplicant foraprons,subjectnheapplicannaveivil penalty of
not more than five handreddo11ms($500). NEW RESIDENfIALELECTR FT.
� p ❑ I,asnwncrtdthcpropcny,ormycmployces with wegex.stheirsnlecnmpcnsutinn, —SQ. STORIES TYPECONSTRUCHON
a3— will dudkovork.andlhe structure isnot inumcbriroffdel formic(Sec.9044,Business
anti Professions Cold-The Contractors License Law does not apply to an owner of
property who builds arimpraves there0v,and whoddes such work himselfonM1roughhis OCC.GROUP RES.UNITS
own employxs,prnvidedthatsuchimpmvementsartnot intemderorrdfcred foraale.If,
however,the buildingor improvement is sold within one year or completion,the owner- .T
builder will have Ilse burden of proving that he did not build nr improve for purpose of
e.
1, as er onto property,am exclusively commctiog with licensed contractors to QTY. PLUMBING PERMIT FEE n.aaD .orvE APN
nor 1the Project(Seo.7044,Business and Professions Code:)The Contractors
000
License Lawdoes not applyto anownero(property who builds orimproves thereon,and PERMIT ISSUANCE
who contracts for such pro is withucmN.nor(s)licensed pumuum to the Gmtmcmr'e pL'I'ER-DRAIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ 1 am exempt unJer Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UT IDs E l
Owner Doc
SANITARY YN_
RECEIPTp
DRAINS-FLOOR.ROOis,AREA,CONI.
WORKMAN COMPENSATION DECLARATION SCI1001.'fAX Y N
❑ Iherehy affirm run l have acenificnte of consent to self-insum,nrncerdfwte nl' RECIJI'TN
Wakcrs'Com tion lnsuranceora anifiedc
FIX'T'USES-PF.R T'NAP
pens. opy Ncreof(S«.3800,Lab C.)which DANK FEE YN
ars al l employee's under this pamrit' GAS-EA.SYSTEM.I INC.4 OLD LETS RECH[Ff p
P011cy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 BDO PLANCHECK FEE
❑ Certifedcopylshumb,fismaked.
❑ Certified copy is ElW wish the city inspection Division. GREASFJINDUSTRL WASTE INTERCEPT'OR GRADING FEE
CER'T'IFICATE OF 17XEMM ION FROM WORKERS' GREASE]RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hi completed iftbe permit is for one hundred dollars($100) SEW17R-SANITARY-STORM EA.200FT. ENERGY IEE
or loss.)
I certify that in the Performance of the work for which this permit is issued,l shall WA TER HEATER W/VENI'Ai1.ECIR
not employ stay person in any manner so as to become subject to the Workers' PAID
z Compensation Lawaof Culdomia. Date WAI'RR SYS'T'EM(I REA'I'ING Dem Ruciptp
Applicant
� 0 NOTICE TO APPLICANT:If,after arckingtris Certificate of Exempti.....ushould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
E-' V) Mcome subject to the Worker's Compensation provisions ons of the Labor Code,you must
a forthwith comply with such provisions o,,his .is ball he dremW invoked. BUILDING IEE
4 CONST RUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which thms is pert is roared(Set.3099,Civ_CJ
Lender's Name
LL. F Lenders Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
U T certify that 1 have read this application and state that the above information Is
conduct.lagreetocamply with all city andcouity onliaancesand state laws miadngm PERMIT ISSUANCE MECIIANICAI.FEE
F" building viestructinn,a ndherebyawhoriumpresentutivesofthiscitymenmruponthe
V z above mcishincd property tar inspection purpose, ALTER OR ADD TO MECI I. CONSTRUCTION TAX
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,M)CFM)
aha granting of this�crWI.
dun /- U ` . / .4 AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of ApplicanUCmntncmr �� V Date EXI IAUST HOOD(W/DUCP) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or furore buildicipi C de,Cap store or handle heva lth a mammal
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 B'T'U) ,TO T'Ah:
CoJc,Section 25532(,)4
Cl Yes ❑No VENTILATION FAN(SINGLE RPSID)
ire
ban
ds
Will the uconcunt ants as defir d by the uy Area Air Quality Management
BOILER-CMP(311F OR 100,000 BTU) ISSUANCE DATE
hoarict' air contaminants as dented by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000BTU)
DiaricT! 051 p
❑Yes ❑No NEW R[SIUENTIAL MECII. SQ.FT. Y' P4
1 have read the incautious,tnmeials req.iremeits ander Chirpier 6.95 of Ore JAN 2 6
California Ilealth.@ Safety Cutand u
Cute,Sections 25505.25533 25534. 1 understand for 1991
if the building does not currently have a tenant,Nat it is my responsibility to notify the J�7
Ourupant of the requirements which most heart(print to source of a Cedi Exam of /5' Y�r
ccupanbcy. 4ur cnlfr
Owner or uutimduJag,nt - Date 'TOTAL: ISSUEDR, VV
OFFICE