24589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO11LDING-ELECTRICAL PERM]TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL f� /I C O(]
IIUILDINGPROJECT IDENTIFICATION - G 4 J o J
BUILDING ADDRESS
/] 1 ',�I^ /� / SANITARYNO. APPLICATION SUBMITTAL DATE
1901 / I ua I L%I • UNIT# LOT It
OWNffiNAME: P� PHONE:1 ��� CO T CTOUR'S NAML:� _ / / LIC O N/C CONTROL#
nAs\RCIIITEL /ENGINEER: LIC NO:/V/ A�� ,— ',V, F,tW/]V� y5�tnrQ ❑
a
CONTACT: PHONE:'
QTY. . - ELECTRIC PERMIT PF,E BUILDING PERMIT INFO
BLDG ELECT Pl. M MECH
PF.RMI'f ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALJOB DESCRIPTION
Q=Z Ihereby aff that l um licensed underprovisions of Chapter 9(commencing with r
X00 Sectton 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
full Funeral if}FI. I� /f /y
FZW Ltcense las:`�'f-70f3 Lm.#_ITVSa Q76 UP TO 200 AMPSIT
m<y Dole �) Commaor -x� 201-IOOOAMPS - ry
NZ, ARCHITECTS DECLARATION 000 OVER 1AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
0ZFO-Q I rediscount]myplansshall be nsed as publicrecords.
P'y F; SIGNS ELECTRICAL E D I N
pppp+-r� Licensed Professional _ V
p, �6
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t
DCO ,PU., I hereby affirm that I am exempt from the Contractor's Licence Law for IM1e ' R
W 3 W m following s and Parana.(Section 7031.5,BusinesProfessions Code:Any airy m county TEMP.METER OR POLE INST. -r
to which requlms a permit m con...m"alter,improve,demolish,or repair any structure POWER DEVICES T c
W �+� mrs"o its issrance.also requires the applicant for such permit to filed signed statement
�O0that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
oP,4 9(cOmmeneing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC y ON
W_, amG)mix exempt lherefmmandthe basis ortheollegedexempimi.Any violation of 7G OUTLETS-SWITCIIBS-PIXTURES Section 7031.5 by Pay applicant for a permit subjects the applicant to a civil penalty of L"-.71/�.�
not-.-,ban E,1 hundred dallurs($500). 5YJ 1.1
'^o ❑ I,asownermfiheproperry,mrmyemployees with wages astheiraolecompe.aloe, NEW RESIDENTIALELF.CTR _SQ.IT. STORIES TYPECONSTRUCTION
63^° wil l Jo the work,and the structure is not intended or offered for sale(See.70TI.Business
and Professions Code:The Contractor's License Law does not apply to an owner of
popery who but Ids or improves thereon,and who does such work himselfor through his OCC.CROUP RBS.UNITS
own employees,provided that such improvements arenot(mended or offered for sale.If,
however,the building or improvement is sold within one year ofcomplmion,the owner- TOTAL:
builder will have the burden of prating that he did not build or improve far purpose of
clPQTY. PLUMBING PERMIT .FP.E- . FLOODZONE APN
❑ I,es the lufact(Sapeny�am business
andely resting,, bll,eosedContractors
License the coastal
pplyto0nc Business and ywhProfo build Ceder)The Contractors
License
PERMIT ISSUANCE
License Lawdoesnotapplytoan Owren ofpopery whobuildsrsimpmvcs thereon,and
Lho icense raw,forsuch projeaewimacomracmr(e)licensed pursuannmthe Contractor's ALTER-DRAIN&VENT'-WATERG
License Law. (' ) - PEE SUMMARY .-- -
_ ❑ I am exempt under Sec. - ,B Is P C far this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dote RECEIPT#
\ DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
Ihembyaffrmthailhaveacertificatoofconsentioself-insura.oracenificae,f FIXTURES-PER TRAP RECEIPT
kens'Compensation
pinesumncaoprpaycenlfiedcopy lhereoF(Sea.3800 Lab C.)which PARK FEE Y N
etvars Polly#1 crI 4.4.I /)Pere/- GAS-EA.SYSTEM-1 INC.4 OU ITEMS RECEIPT#
BUILDING DIVISION FEES
Company, - - --
❑ Cified copy ie hereby furnished. GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
e
entified copy is filed with the city inspection division. GREASEtINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASE'I'RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completedifthepetmit is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE.
err last]
(certify that pa,o pin an,arrear the work he become
is issued,)shall WATER HEATER WNENT/ELECTR
not employ any person to any moaner so es to become subject to @e Worker% pglp
Compensation Laws of Cnlifomia. Date WATER SYSTEM(TREATINO Data Receipt Jr
Q C, Applicant
7. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL TIME. SQ.Fr. TOTAL:
HW become subject to the Worker's Compensation provisions of the Labor Code,you must
� ; fonhwith comply with such pmvisiona ,,his permit shall be deemed.,nkat]. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FFP
.7. Z I hereby affirm thin there is a construction lending agency for the performance of TOTAL: z, ELECTRIC FEE
U O the work for which this permit is issued(Sue.3097,Civ.C.)
Leede :Name PLUMBING FEE
U Lena .Aad .aa QTY. 'MECHANICAL PERMIT ' PEEL r 5
1 canny that 1 have mad this application and state that the above information < -
�-e correct.)(gree to comply with all city and county ordinances and state laws relati goo PERMI'P ISSUANCE MECHANICAL FEE '
U z building construction,and hereby anthems,representatives ofthis city to enter upon the CONSTRUCTION TAX
above-mone
entid property for inspection purposes. ALTER OR ADD TO MECIi.
(We)signs,m save,indemnify it keep hermltze the City of Cap,rinn against
finish ,udgments,,mas mcla.p,nsss whodnIstsain anyway accrue against said City AIR HANDLING UNIT(TO 10,000CFM)
in use P fthegmmin of ' permit '
A AIR HANDLING UNIT(OVER 10,000 CFM)
Sign rm of ApplieanUC rem Data EXHAUST HOOD(W/DUCT) PAID
HA ZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10 100,000 BTU) Dale _ Receipt#
Will the applicant or future building occupant store or handle hazardous material 017e V1�
as detlued by the Carman.Municipal Code,Chapter 9.12,and the Health end Safe,, HEATING UNIT(OVER I(Q000 BTU) TOTAL:
Code,Section 25532(a)R
El Yaw CI No VENTILATION PAN(SINGLE RESID)
Will lM1eapplieuntorfuture holding occupant use equlpmevmnties leas which emBOILER-COMP CHIP OR it 1.00,000 BTU) ISSUANCE DATE ,
hazmd,m air contaminants us defiPcd by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU
plavla7 9 D
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,Ff.
1 have read the hazardous materials 5505.2553ts under Chapter understood
of the JON 2 6 1993
if the uil Health&Safay Code,Sections 25505,25533 and 25554. I icy to notify
chat
ifthebuildingt]requirements
whaveatenant,thatttis my responsibility a tonotifythe
occupant y.IM1e reduirements which mull b,met prior m issuance o[a Certificate of
Occupancy.
y. rlNr t , cnulvU.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE