24612 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY PERMITNO. 24612
BUILDING-ELk:CI'NICAL
CITY OFCUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICA).
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS: I / / /)r
yIr
UNITM LOT 11 {(�lP
OW RSN E: pit CONT 'S NAM r N/C CONTROLa
UI ❑ J
ARCHI'IECT/ENGINEER: LIC NO: ADOftP$�/'I�aa�ayy��
CONT : f MPHONE' J--� QTY / ELECTRIC PERMIT FEE BUILDING PERMIT INFO
VI� HIMELECT PLUMB MECPER
`JI
PERMIT ISSUANCE ❑ ❑ ❑
C NSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I herehyelEtm atlolnlicenscd under fChapd,..nd(commercial,with
00 SCCllon]Wd) DivisionJof the Busin<va vtsto C de,and my license is in PANELS _
full force nnJ f n UPT0200AMP5
G V License Class Lica
yQy Dam Contmmor 201.1000 AMPS SQ.FT.FLOOR AREA $/
ARCHITECTS DEC, OVER 1000 AMPS
ZO y 1 undenlwd my plans shall be used ae public rccoNs. . ® i
OyWWWG SIGNS ELECTRICAL _
Q '1 la
Licensed Profesvonal SPECIAL CIRCUIT/MISC. 1
Y yjy c'Ua OWNER-BUILDFR DECLARATION
KOpW, I hereby aflirtn that 1 am exempt from the Contractor's License Law for the TEMP METERORPOLEINST. J C
W3LLti fallowing mason.(Section 7031.5,Business and Professions Cade:Any city or county 1
�y� which requires a per m to construct,alter,improve,demolish,or repair say structure POWERDEVICES
K�Q� priarm in issuance,alaortyuires the applicant for suclspemtitto file.signedstammenl 7 YYY
W ht p that he is licensed pursuant
pursuano the provisions of the Communes License Law(Chapter SWIMMING POOL ELECIRI V UATION
L0.o�' 9(commencing with Section 7000)of Division drifts,Business and Professions Code)
W^y or Nm he is exempt therefrom and the basis fonhe alleged exemption.Aayviol.toaof OUTLETS-SWITCHES-FIXTURES
p.ZQ Section 003 IS by any.Whcard far.permit subjects theapplicam to is civil Penalty of
mar
I me than five bundred dollars($50mNEW RESIDENTIAL LLE _SQ.Ff. STORIES Y'YPECONSTRUCTION
cat
❑ I.as6wnmofthepmperry,oTmyemployeeswithwagesMNeirsolecompensuuoa,
o. will do lhework,and the strucwrcis not immridedoroffemd for sale(Sec.]094.Business
.it Professions Crede:The Comracmr's Liana Law does nm apply to an.weer of
property who buildsorintprovesthereon,.adwhodoes such workhimselforthrough his OCC.GROUP RES.UNITS
.wm entployees,pmvi ded that such i mpravements am not ime adedor offerr4 for sale.If.
however.Nebmicting or improvemem is sold within one yemofcomPletion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
,air.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ l,mownerofMoproperty,.mexclusivelycontraaingwithlicensalcontatomm
construct the project(Sec.7044.Business and Professions Cade:)The Contractors PERMIT ISSUANCE
License Law docs not apply m an owner of property who builds or improves thereon,and
who commits for such projects with ncomrectods)licensed pursuant t.the Commetors ALTER-DRAIN&VENT-WA'TEit(RA) FEE SUMMARY
License Law. ID,FE
❑ I urn exempt under Scc. B&P C for This reason BACK FLOW PROTECT.DF.V ICE SANITARY Y ID_N
cEiPr a
Owner Data DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX NECEIPfa N
❑ Ihrmbyaffira that l havenceridcole ofcaaunno self-imum,oracerifiramof MCFURFS-PER TRAP PARK FEE Y_.N—
Workers Compensation Insurance or.entified cagy dmrcof(Sec.3800,LabC)which RECEIPT a
covert,all employee s under this permit. GAS-EA.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FEES
Policy a
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenifiedcopYis herebyfumished.
[3 Certified copy is bled with the city inspection division. GRHASFWrNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PFJ:
COMPENSATION INSURANCE
('this semionneed not be completed ifthe Permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA,YOOFT. ENERGY FEE
or less.)
I certify that in the perforrtumcea the work fm which this permit iaiuucd,I shall WATER HEATER W/VFNT/ELECfR PAID
not employ any person in any manner so as to become subject to the Workets WATER SYSTEMfTREATING Dam Receipt a
Crau'romioalawxof CWifomia Date
O z Applicant NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
r4 become subject to the Workers Compensation provisions of the Inbar Cade.you mull BUILDING FEE
7 forthwith comply with such provisions or this permit shall N,deemed revoked.
SEISMIC FF:L
E CONSTRUCTION LENDING AGENCY
Vz I hereby affirm that i.a.mom omm leading agaacy for the performance of TOTAL, ELECTRIC FEE
O the work far which this e padt is issued(Sec.3097,Civ.C.)
U0 lenders QTY. MECHANICAL PERMIT FEE Name PLUMBING FEE
lender's Admcent
di
C) 1 certify elm 1 have read this application tred stem that the above aw,oc mi.a is MECHANICAL PEE
0. correct Ingrtelocomply with ell city and county oNinencn end stem laws relatingm PERMITISSUANCE CONSTRUCTION TAX
71 buildingconstmction,end herebysamunce mpresemativeso(chis city to enterupon the ALTER OR ADD TO MECH.
U 7 shove-mentioned None"for inspection purposes.
f-i (We)agree to love,indemnify and kap hmmiess the City of Cupertino against AIR HANDLING UNIT(TO 10.000 CFM)
liabiliti x,judgmenn,costs and expenses which may in any way sc<fuc.gaima said City
in consequence of Ne granting of this petted. AIR HANDLING UNIT(OVER 10,000 CFM)
Date EXHAUST HOOD(W/DUCT') PAID
Si'stumof Applicam/Comraztm Date Receipla
HAZARDOUS MATERIALS DISCLOSURE HIiATING UNIT(TO 100,000 BTU)
Wllldte.pplicant or(.,am building occupant store or handle hnsmdons material HEATING UNIT(OVER I(IO,OW BTU) TOTAL:
refined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
u
Qalee,Smion 255]2(e)] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSLIpjgC ' ^
BOILER-COMP(JHP OR 100.000 B'N) �P+' qq V
Will air cmlcantorfu ad refund by the
Me Area
Aire Quality
ceswM1ichemit
"miii7a air conlolninann M defined by the Bey Arra Air Quality Mnuagemenl DOILER-COMP(OVER 100,000 BTU)
qJ ❑Pea ❑No NEW RESIDENTIAL MECH. SQ.FI'. JAN -5 1994
1 have read the hMardous materials requirements under Chapter 6.95 of the CITY Ur CUrc
Califomia I IeWth&Safey Cade,Sections M505.35533.nd 25534.1 understand Nat
if the building does not currently have a tenant,that it is my responsibility to notify the
.ccupam of the ox,mormrma which must be met prim m issuance of a Certificate of
Occupancy.
Owner or autharixd agent Dole TOTAL: ISSUED BY:
OFFICE