24717 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - Bull"
DAN'G.eLNU I RICAL PERMIT NO:
APPLICATION/PERMIT PLUMBING.MECHANICAL 24717_
]BUILDING DIVISION , � BUILDING PROJECT IDENTIFICATION,
BUILDING ADDRESS: - SANITARY NO. APPLICATION$1\U13MITTALDATE
— LIAlitli 711A FINfas IAT#
OWNERS NAME: PH NE: CONTRACTOR'S NAME: LIC NO: L
4 i7 O
ITEC /E N R: NIC CONTROL
• AR LIC NO' c-J ADDRESS
I - Sf'/-O 4 e
CONTACT: PHONE:
QTY, ELECTRIC PERMIT f ' - FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB M H
PERMIT ISSUANCE El El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
omz Iherebyaffirm tout l am licensed underprovnsionsof0equar 9(commencingwith
WF OOSection 7")of Dlvlsinn 3 of the Business and Pmfessime,Code,and my license is in ppNELS
y�V F full force an'eft L .I�f
—Zed License Classff y ltC,�—r.ic.# INTO 200 AMPS
Fly Dn[e ��• Contractor 201-1000 AMPS
ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
ZO_Cf Iunderstandm In hll be residua blicrecords. OVER 10110 AMPS
r4`- YPa ssa pu
�m�; v SIGNS ELECTRICAL
.,...11 Licensed Professional
�¢aQ OWNER-BUILDER fresh DECLARATION SPECIAL CIRCUIT/MISC.
p.H I hereby r.(Section
than 1 am exempt from the Elevation,
License Law foe We
fiflImeW
to
whichlncoiledmermit to 7031,5,mireamBusiderse and Professionsh,or haat An,pity or county TEMP.METER OR POLE[NST.
�7 whishrequiresupermit t000re,the,ulcer,impress,demolish,fi rep air anystructure
WgrpY0 prior to ilicensed also requires thesioiwnlfar the Commoiiuo file.signed statement POWER DEVICES
O that 9(comiencing with Smiou7001.the provisiiser in 3 of Contmmo/s License Law(Chapter
PXo 9(commendng with Section9000)of Dlvlsinn3 of the Business and Pro[essioncGge) SWIMMING POOL ELECTRIC VALUATION
that hens exempt drerefrom and the basis for lhealleged coerfaim,Anyviolationof .
C Section 9113 L5 by any uppliwnt for a perrOUTLETS subjects the applicant to a civil penalty of SWITCHES-FIXTURES
not mom then five handred dol In,,($500).
prop y yemp y g Tensa NEWRESIDENTIALELECI'R S .FF
C ❑ l,asowneroOhe ert,orm Io ceswithwa esastheirsolecom tion, _SQ.FF TYPE CONSTRUCTION
ywill do the work,and the snecmre is not inlendedoroff d forsnle Eine.901 Business
and Professions Code:The Contractor's License Law does not apply In an owner of
pmpertywhobuildsnr nmprovesfhemon,andwhodoessuch work himselforthrough his
wnempinyees,pmvided Nutsuchimpmvementsurenolintendedorofferadforsale.If, OCC,GROUP RES.UNITS
however,the buildingorimprovomentN sold within one yearlfcompletion,the owner- TOTAL:
builder will have due burden of proving that he did not build or improve for purpose of
_ sale) • . r
❑ I,m owneroflhe property,am exclusively contrasting with licensed conbnetoire QTY.: r PLUMBING PERMITll
DZ APN
consumer dm project Sec.9044,Business and Professions Cale:)The Contracrods YYY TTT '•r'
( olves PERMIT ISSUANCE LicenseLovell
In lye with ar of roustabouts)
)wbosedloorion wine
Contractors
who contracts forsuch projeetewlUeconlmemr(%)licensed pnrsonmwthe Convector's AIAER-DRAIN&VENT-WATERTA M ARY
License Law. )
E] 1 um exempt under Sec. ,p&P C far Phis mason BACKFLOW PROTF.C9'.UEVICE DTE TSIDE EES
Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,CO #
• WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ [hereby affirm that l have aeerlificate identical toself-Insure,ora certifeateof FIXTDRE$-PER TRAP RBCEIPT#
Workern'Compenxa[ion lnsumnaa orocenlBW mpy thereof(Sea 3g00,Lab C.)which PARK FEE. Y N
corers all ample se's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company—t7y-Pf-,46 OA GAS,EA.SYSTF,M-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby fumished.
Certified copy,is filed with the city inspection division, GRFASF/INDUSTRL WASTE,INTERCEPTOR GRADING IiE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This situational non be completed ifthepermil is mrane hundred dollars($100) SEWER-SANITARY-STORM EA.2o0F1'. ENERGY FEE
or less.)
I certify that in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/HLECTR
not employ any person in any manner so as to became subject to the Workers PAID
Coundaro mu Lawsof Culifnto.. Data WATER SYSTEMITREATING Date Receipt is
0 Z Applicant
Z 0 NOTICE TO APPLICANT:If,surer making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL:
r+ V) became subject to the Worker's Compensation provisions of the Labor Cale,you must
moi , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
(hereby afford that there is a construction lending agency for the performance of 'TOTAL: ELECTRIC FER
L) O Ibfor o work which this permit is nssueI(See 3099,Co.CJ -_
Lenders Name
F-'
Leader a Addous QTY_. WECHANICALPERMTT, ?:FEE PLUMBING FEF.
C..) I c I fy thou I have Lead this application and smte that the above mformmir ' '
correct.I g I hmplyw[hallctyandcountyordinanwsendsnamlawsrclatingt- PERMIT ISSUANCE ��n MECHANICAL FEE 330`
E" V) bandingeansnuction,and hereby authorize representatives offhts city menteraponthe
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Q O CONSTRUCTION TAX
(We)agree to save,indemnify and keep becomes,the City of Cupertino against
liabilitics,jadgmemf.Astmadexpendawhich may in any way accn®agoinst slit City AIR HANDLING UNIT(TO 10,000 CFM)
casae, of the gmmfng
AIR HANDLING UNIT(OVER 10,000 CFM)
no of icant/Contractor (J Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dore Receipt M
Will the applicant or future building oecupa st store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)9
11 Yes 0 N VENTILATION FAN(SINGLE RESID)
nISSUANCE DATE
Will rhea Iicam orfumrc buildingeases BOILER-COMP(3HP OR 100,000 B9'U) T A
hazardous air mntuminants as dcfned by the Bay Aced Air Quality Management BOILER-COMP(OVER 100,000 HTU
Dismict1 ( )
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ��� �
I have head the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that ^y
iftbe building dada not currently have a tenant,that it is my responsibility to notify the I']r Ur CUP'j
received of file requirements which mush be met prior to Issuance of a Certificate of L I
Occupancy.
Owner mo lmnized agent Date TOTAL 3" ISSUEDBY:
OFFICE
i