24577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL
CITU'LITCiJPO L. PERMIT NO.
BUILDING DIVISION
s1oN APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION 24577
BUILDING ADDRESS �/►�{' I�, J. SANDARYNO. A/PPPLICA'BON SUBMITTAL DATE
.3 ■ , UNIT# LOT#
OWN' S E: PHO E: W CONT CT R'S Ndd/fr _ LIC NO: l lV
\V\ii�f'J� /� N/C ARCHITECT/ENGINEER: LIC NO: ADDRESS: J LtS33ro
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. EI.ECTRICPERMIT FET,
BLDG ELECT PLUMB : H
PERMIT ISSUANCE ❑ ❑
LICENSEDCONTRider,a SDs,cf Ch TION - pppLIANCES-RF.SIDENTIAI. 3- Oyu>1'ffRli'TION
DaZ Thereby off ECnmdund TOR islomof RATIO (commencing with
[ 00 Section 70W)of Dlvison 3 of the Business and Profession,Cale,and my license is in PANELS
FaVF License
Clafall defl'em. t � �
66'Zy pU)U License Class l,ie.# UP T0200AMPS
N6y Date Convacmr 201-IOW AMPS
Z FO no ZZ- ARCH ITECT'A DECLARATION OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.FI'.
O I unJernanJ my plain shall be used as public records.
W SIGNS ELECTRICAL
Q Licensed Pmfessmnm
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Prc)XB, , I hereby affirm that)am exempt from the Contmclods License Law for the
F�"e following mason.(Section 7031.5,Business and Professions Code:Any city natural; TEMP.METER OR POLE INST.
pp .] which requires I'mo permit to cones d1c almp improve,demndill fi repair any structure -
2 a�
that
heirto slicensed parmnt to the
Nrovisins ftleuchpemtors License
Love indooriummera POWER DEVICES
tt�tCCll❑J0p thatpeislicensedpursuom totheprovisionsof the Contractor'snal tom Lawne Ctelip
9(mmmenciug with Seniors 7000)af Divisirn3 ofthe Business end Pmfaeions Code) SWIMMING POOL ELF.C'I'RIC 111+++pppLUATION
ly_y
or he is exempt tormfroin and the basis for alleged exemption.Any violation of 1 C 1"T N
E•, a See"70315Is 'a applicant for u permit subjects the applicant a civil penalty of OUTLETS-SWITCHES.FIXTURES Y.
•ay not more than Flve hundred dollars($5fN1).
p ❑ I,as owncrofthe NEW RF,SIDENTIALELECTR Fr.
propertturepremployed with —SQ. Ih CONSTRUCTION
i3— will dothoters Code:
The cmrersnoris Liceo,La doesed am apply tloan,Business - �z
pro Professions Cade:TM1e ves doecmds ndwho Law does not apply lf an owner of
propenywhnes,proorimphat said,
who are ssucamidedimselfor through his
own emplthe oyees,por nonsuch improvements sold within
neyear aedorofferal n,[liera.If, RF. .—UNITS
ImIdillhabuilding teburden of provin that a di root build of completion,purpose of
build however,will have the burden of proving that he Aid not build or improve for purpose of TOTAL:
QTY. PLUMBING PERMIT 'PEH' FLOOD ZONE
ownerof the properly,nm exclusivelyeonvammg wrthlicensed conitectorHt P p APN
n1 act the protect(Sec 9044 Business and Professions Code)The Contractors
License law does nmapply toanrwnerofpropery whobuildsorimproves thercar,and PERMIT ISSUANCE
whocamrans brothel,projects with armhowlar(s)licensed pursnanrw the Commcme,
License Law. ALTER-DRAIN&VENT-WATER(EA) - - FEESUMMARY•
❑ 1 em exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
OwnerSANITARY YN
Dam DRAINS-FLOOR,ROOF,AREA,CONI. RECEIPT If WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
Wo ers Compenrtn,hnllhnveeeortaverte0f consenterof(Sec.380,ace d.)which FIXTURES-PER TRAP RFCE1P #
Workm.�Crmpansationlnemmnce orawrtifed copy thercoP(Sec.3500,Lab CJ which PARK FEE Y_ry
rs all employees under this permit.
Policy# GAS F.A.SYSTEM-1 INC.4OUTLETS RECEIPT#
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnishM.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE -
- TTTissectionnend nor,he completed ifthe permit is fnrone hundred dollars($100) SEWER-SANITARY-STORM EA.200F.
or les ) ENERGY FEE
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER WNF,NT/ELECTR
bot employ any person in any manner so as m become subject In the Worker,' PAID
Campernation Lawsof Celifrmm. Data WATER SYSTENIVIREATING
Applicant Donee Receipt#
O 7-+
Z 0 N09'ICE TO APPLICANT:If,after making this Cenifoadeof Exemption,you should NEWRESIDENTIALPLMIL SQ.Fr. TOl'AL.
becomceubjecttotht Worker's Compensation provisions of the LeNtrCWe,you mom -
frrhwhh comply with each provieintrt er this fern],shall be damned ravokod. BUILDING FEE
p, CONST RUCTION LENDING AGENCY SEISMIC FEE
Z
^a I hemby afford darters iso construction lendingagenoy for performanceof
L) O de work for which this peril is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
ry
Leader's Name ,
Leaders Address QTY. ' MECHANICAL PERMITi FEEPLUMBING FEE
1 certify the 1 I e read this application and nate reach,above information is r
correct I agree to complywth all cdy and county ordinances and stem laws relating to PERMIT ISSUANCE �.n MECHANICALFEE
building construction.and hereby authorize representatives of this cityto enter upon the
U Z above-mentimai properly far inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree ormom,indemnify and keep humorless the City of Cupertino against
liabilities,judgments,costsandexpense ich may auto accrueagromesud City AIRHANDLING UNIT(TO 1o,W0CFM)
eowenwgofdds it.
� AIR HANDLING UNIT(OVER I0,000 CPM)
( L
A atureof Appliam/Convnnor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the affluent,or furore building occupant store or Fondle hazardous material
as defined by,he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section Ya32(v)P 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP CHP OR HEJs)d BTU ISSUANCE DATE
Will deapplieantorfumrebuilding occupant use equlpmemnrdevices which ami, (' ) _ PAID
� T� y �j
hazardous air armorer as de fired by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 RTU) P A II D
WLDisvict"
❑Ves ❑No NEW RESIDENTIAL MECTL SQ.FT.
1 have read the has materials requirememe under Chapter fl95 of the DEC ����
Califonda Health&Safmy Code,Sections 25505,25533 and 25534. I understand that '
if the building does not curently have a renam,that it is my re,pensmai,y to notify the
pe pant rP the reyuirentoms which mart be met prim to Iseuvnac of a Cenifcam of (;L rGrl I B`-'�
mr,aney. Cf(r \u�rj
Ownerormahanzed agem Date T ISSUED BY:
OFFICE