24462APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . kaTCTRICAI-
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION - IIUILDINGPROJKO'I'IDRNfII41;A'1'ION4ii,
I'f:RMIT NO.
24462
BUILDING ADDRESS: / J
101F-5- UNIT It LOTH
SANITARY NO.
IH
APPL{{{'II/CATIIO.N1SSU�U1B�MI'ITA`L0,(O
JN
`
OWNERS NAME PHONE.
ns
V
7, N oy
NIC
❑
CON I KOL0
ARCH ITECTMING [NEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY.ELECTRIC PERMIT FEL?
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PF.RMITISSUANCE
El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed underprovisionsofChapter9(commencingwith
APPLIANCES - RESIDENTIAL
JOB DESCRI ON
PANELS
UP TO 200 AMPS
Section John) of Division 3 ofthe Business and Professions Code. and my license is in
PoII face and effect.
J License Gloss Lia# bZ��-S
Date Connector
A A
q (/ �' \ i �F
201 - Halt) AMPS
ARCHITECTS DECLARATION
l underrt' my plans d as public res.cord
OVER Ihigh AMPS
SQ. FT. FLOOR ARBA
$/SQ. PT,
SIGNS ELECTRICAL
I/. 4,21.0--
/� II p�\�
^ /.\ Lr" g Y
p
\ "�
License naonel OWNRRBUILDER DECLARATION
1 hereby affirm that 1 vin exempt from the Contractors License Law far the
following rtasoa(Section 9031.5. Business and Professions Cade: Any city art county
SPECIALCIRCUIT/MISC
TEMP. METER OR POLEMIST,
which reryires a pemtit to construct, alter, Improve, demolish, or repair any structure
I "VII I,-'
prior toils issuance, alsorequires the applicant for such perdirta file v signed statement
j that he is licensed pursuant to the provisions of the Contractors License Law (Chanter
9(commencing with Section 7") of Division 3 of the Business and Professions Code)
POWER DEVICES
SWIMMING POOL ELECTRICDAT-
f
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant fora permit subjects the applicant m a civil penalty of
OUTLETS - SWITCHES - FIXTURES
1 dot more Nun five hundmd Aollurs($500).
❑
wrk,andthespeny,armyempendedorofwagesnsme
NEWRESIDENTIAL ELEC'IR _SQ. IT
STORIES
TYPE CONSTRUCTION
othe Sse.compensation.
044. Business
will dothework, and the structuremdrnintended erroffered fatalepply
and Professions Code: The Contractors Law does not apply to an owner of
t
nd who
propownenywho yess, provided
impmvesth improvementsamnodoes tchwankhimsfeared hmugh his
improvements tineneyourdedarmfnon,
OCC GROUP
RES. UNITS
TOTAL
howemployews,dividedthinsuch
theo nlr.
or« prove for the owner-
builder, v mw have
alder will have the harden nl proving that he did not baud or improve ran Pdrpose of
the h n impmvemen is hatA a within one build
QTY. PI,UMDINC PERMIT'. $LLE
s
.ale.)'
❑ I,solo%nerofthepmpeny.amexclusivelycon0aaingwiNlicensedcontnctonto
FLooD ZDNe
qPN
comwn the pmjwet (Sec. 9014, Business and Professions Cade:) The Conuactors
Licenx Low Jews not apply to an owner ofproperty who builds or improves thereon, and
F PERMIT ISSUANCE �•
who contracts format projens with acomractor(s) licensed puuuant to the Connector's
License Low.
ALTER (FA)
: ,FEE SUMMARY
❑ 1 um exempt under Sec. , B At P C for this reason
BACK FLOW PROTECT. DEVICE
,IDI:
FEE
Owner Date
ROOF. AREA,COND.
SANITARY Y —N -
RECMPTp
WORKMAN COMPENSATION DECLARATION
'a❑ IhertM1y affirm thatlhvve accrtificate of conaenuuself-ensure,mvicenificate of
Wonkera'Cnmpensation Insurance or teenlOeA copy thereof (Sec. 3800, Lab CJ which
--SCHOOL
SCHOOL TAX Y N
RECEIPTp
FIXTURES - PER TRAP �.r.l
PARK RiR Y N
GAS - IA. SYSTEM -I INCA OUTLETS
coven all employee's under hix permit.
PPIiwY #
RECEIPT' #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ CenifiedcapyisherebY.fumishcd.
❑ Cenified copy is filed with the city inspection division.
GREASFONDUSTRL WASTE. INTERCEPTOR
GRADING FEE
CERTIFICATE 01; EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS PER
SEWER - SANITARY - STORM F.A. 200FT.
ENERGY ITE
(This section need not be completed ifthe permit is for one hundred dollars(SIM)
artless.)
WAT IVENTMiLECR
I certify that in the performance of the work for which Nis permit is issued, I shall
not employ any person m any manner so as to became subject to the Workers'
PAID
Compens:nian Leans of California. Date
Applicant
ATERSYSTEM?R TING ���
Due Recwipt#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should71T
become subject o the Workers Compensation provisions of the Labor Code, you must
.NTIAL PLMIL SQ. ter.
TOTAL:
Forthwith comply with such provisions at this permit shall M deemed revoked.
BUILDING FEE
—177l,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby uIf,rm that there iso rana- rim leadingagency for the perimommerof
ELECTRIC ITE
the work (ern which this permit is issued(See3099, Civ. C.)
Lender's Name
Lenders Address
QTY. , .. MECHANICALPERMIT':,},(sy'i. FEE
PLUMBING FEE
1 certifr the 1 have barl oris appueatmd sad state mat me above information is
PERMfI' ISSUANCE
meet. l agree to comply with all city and county ordinances and state laws relating to
MECHANICAL FEE
building construction, and hereby authorize representatives ofthis city to enter upon the
above mentioned property for inspection purposes,
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
(We) ego. 10 save, indemnify and keep harmless the City of CapeNno against
liabilities,judgme costsand expemcs which may, in anyway acctne against said City
AIR HANDLING UNIT (TO 10,000 CFM)
he grunting of th' -_
y�
ATR HANDLING UNIT (OVER 10,0(10 CFM)
S' Applicum/Cnnhuvm Data
EXHAUSTHOOD (W/DUC'i)
PAN
HEATING UNIT (TO I00,000 BTU)
IWA RDOUS MATERIALS DISCLOSURE
Date Ji
Will the applicant or (lure building occupant store or handle hawdous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
- TO L
Code, Section 25532(a)9
❑ Yes ❑ No
VENTIIA'1'ION FAN (SINGLE RPSID)
WilltheapplicantnrfmurehuilJingoccupent uw equipment ardevias whichemit
BOILER - COMP(JHPOR 1110,000 BTU)
IIS§YANCE DATE
Asvab's air contaminants as defined by the Bay Area Air Quality Management
❑ Yes ❑ No
NOV 10X992
BOILER- COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ, IT.
1 have read the hazardous materials 5505.25533 odder 34. 1 mr earm nd the
'California Health & Safety Code, material255o5. naimnermat and 25534. T understand thin
( /�k� /v
f r OF Currr11 INV
if the building does not ermeraly have a termm, that it is my responsibilitym early the
occupant of the Acquirement which must be met prior to issuance of a Cenifacan, of
Occupancy.
ISSUED BY:
Owner., and hnri'zed.,at Date
TOTAL:
OFFICE