24914APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOHCUPERTINO HU1LD:G- ELECTRICAL.
BUILDING DIVISION APPLICATIONAIERMIT• 'LUMBNG- SNCUANICAL
BUILDING PROJECT IDENTIFIC'AI'i(1N
PERMH'NO,
4
RIJILDINO ADDRESS:
L- /d IF# LOT#
SANITARY NO.
APPLICATION SUBMITTAL DA'Hi
92,
v
W NAME: 1'IIONE:
CONTRACTOR'S NAME: LIC NO
NYC
❑
CON I'ROL0
<Cffl'IECC/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PRONG:
QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB _ Mfi❑CII
LmT/
�
PERMIT ISSUANCE
LICENSED CONTRACTOR'S ;CLARATION
I hereby ration that I am licensed anderprovisions tfChapter9 (Commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
UlIT02MAMPS
Section 91N10)of Division3nl the Buyincv's'rnA Profueione'Cadq and my llrenso is in
full Bone am e
j License s La,4 O
C�—
Don ECFSo
ANhall be used nc N
� 1 understand my plans shall be used as public recuNS.
201 1000 AMPS
J
OVER 1000AMPS
SQ. IT. FLOOR AREA
,
$ /SQ. IT.
SIGNS ELECTRICAL
Licensal YmfcssinnN
BUILDER DECLARATION
Or
SPECIAL CIRCUIT /MISC.
I man
1 hereby n. (Se that I am exempt from the Convenors License Law for the
TEMP. METER OR POLE INSI'.
t or county
con L5,BUSinassandve,
-
whifollowing h equires apSection
requires a permit an demolish, or nenycity
ad alley improve, demolish, or repair any structure
prow imcensedIarmact ,h the applicant for uchpermius
mires
POWER DEVICES '
thathe LicnseLaJ(Cement
0n he is licensed pursuant .,he provisions of the footman,a License Law (Chapter
' 9(cammmocing with Section 7(HIO)nf Ulvinion Jnl tM1O BUSinns and ROfosslons Code)
nr that lore is exempnhemfrom and 0e basis for the allege ]exnnption. Any violation of
Section 7131.5 by any applicant for a permit subjects the applicant u civil penalty of
SWIMMING POOL ELECTRIC
VALIlAT10N
/�� /
OLO LEIS- SWITCHES- FIXTURES
not more than rive hundred dollars ($500).
❑ I, nxnwncroflheprnpedy, ormyemployeeswithwagesusdneirsnleoompcnsmion,
NEWRESIDENTIALELECfR_SQ, IT.
STORIES
TYPE CONS I RUCTION
will do the work, and the svun on is not intended or offered for sale (Sec. 7014, Business
and Pmfessions Code: The Cramicase. License Law does not apply lo an owner of
property who hul Ids or improves thereon, and who Bros such work himselfor through his
emplUyees, provided thw such impnrvements arc not imended or offered for sole. I L
OCC.GR011P
RES. UNI'CS
TOTAL:
however, the building or improvement isuld within one yearofcompletion, the owner-
builder will havi the burden of pmving that he did not build or improve for purpose of
'
Qom'
PLUMBING PERMIT
FEE?
❑ I,asownerenheMr ny, amexcros lvelyenmmningwianlicensedconuacwralo
I'hoOD ZONE
nrN
o.. man the project (Sec. 7(M4, Business and limitations Cade:) The Cantmnors
License Lawdoes not apply lo an ownerofprolvny whobuilds orimproves thereon,
ERMITISSUANCE
whocommen for such projects with a eonamenrls) licensed puntantto the Cornmem'
License Inw.
A1.TIiR- URA1N &V WA'1'PR FA
( )
FEE SUMMARY
❑ I um exempt under See. , B & P C for this r aeon
BACK FLOW P .DEVICE?
FIT I , FEES
SANITARY YN
RECI?IFI'N
two r Date
WORKMANCOMPENSATION DECLARATION
=COMPENSATION
DR NS
,ROOF,ARE
SCHOOLTAX YN
1 hereby affnn the I huve of umsem to self- insurt, or a certi(cute o
Watkins ' Croo,paen9s lilioynnllnywrunrem ucerlifieed ropytlonvol Sec.3fllq, Lab 0.J whicM1
RECEIPT N
P
S -PBR
PARK PEIi Y N
ey all [ dQ*' / �� p
Policy N
GAS . S Blsl -1 INC. a OUTLE S
BUILDING DIVISION FEES
C m,.rr enA— cG7kfl- ��Gx�—
GAS - EA. SY. EM OVER 41(3A)
PLANCI IECK FE 17
❑ fed mpy ns�islseG.
GREASEnNDUSTRLW STE INTERCEPTOR
GRADING FEE
Certified copy is filed with the city inspection division.
CURT HICAIH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRI?ASE TRAP
SOILS FEE
EWER -SA TARY� STORMEA.200FT.
ENERGY FEE
(This section need not last completed ifthe permit is forone hundreddollan($100)
or less.)
WkKI.01611ATHR W/VHhFDELEcFR
I certify than in the perfanamsweofthe work for whirb,hia permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers'
PAID
WATER SYSTF.M(TREA'1'ING
Dam Receipt#
Compenation Lrwsof Cnliformar. Dane
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. PT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING PEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 hereby affrm Ibat them is a eonsumnimi lending agency for the,somarrams, of
the work I'or which this permit is i,mal (Sea 3097, Cis. CJ
Lett Name
'TOTAL:
VLECTRIC FEE
a
Lenders Acidness
QTY.
MECHANICAL PERMIT
PEE
PLUMBING FEE
I certify her 1 hove read this application anA alone that the above information is
met. l agree to comply with all city and county ordinances and state laws relming b
PERMIT ISSUANCE
MECHANICAL FEH
buildingcnnswniun, anJhereby emh9riu repreunlotivex ofthis dry m enter upon the
above- mcmioned ampcny for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) ngme lo save, Indcnmify and keep harmless the City of Cupertino against
Iiabildies.judgmems, costs and expenses which may in my way moome against said City
AIR HANDLING FRO (TO 10.00) CFM)
in consequence of the granting of this permit.
AIR IIANDIA NO UNIT (OVER 10,000 CFM)
Signnure of Applicant /Comracmr Date
EXI MUST 11001) W /DUCT)
PAID
HEA'I'INGUNIT(TOI00,0001311J)
Dam RecelptN
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre bull'goccupantamren handle hazardous materiel
as defined by the Cupertino Mu ' al CNe, Chaper 9.12, and the Health and Safety
HEATING UNIT (OVIiR 100,0)0 BTU)
AL:
VEND IhATION FAN (SINGLE BE ID)
Code. Section 25532(a)7
❑ Yes No
Willtheapplicant orfuwre bail' goccuhe use equipmemor Jevi<eswhichcmn
rdous at, conmminanu art Cal by the Bny Arau Air Quality Management
OistdclP
BOILER- COMP(JHPOR 100.00)BTU)
I5$ A E 'PI.
FEB
71995
BOILER- COMP(OVI?R 100,000IiTU)
❑ Ycs No
Cry
NEW RESIDENTIAL. MECH. SQ. FT.
I have real the terry Cards materials 5505.25533 m1An 34. 1 understand erst of the
CaBfo ha Health a bare Code, mationa 25505, 2553] m der'Ch 1 er 6.95 oral Thal
u
Vi (i(�r4JLUll�
l,1
if the and, not curuntly have. noant. that it ism mibilityto notify the
ccupmn nCl pniremem win a be d prior t e of a Cenilimno o[
Occupancy.
ISSUED I {y;
Owner nrn 'zeA agem Date
TOTAL:
OFFICE