24582Baal ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING - ELECTRICAL
CITY OF CUPERTINO PLUMBING -MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PRIDE ACT IDENTIFICATION
PERMIT NO. �I C
- 24' 5 82.
BUILDING ADDR/WE�SS: �/I� q14JC4A �
D �/ •/ UNIT# LOT#
SANITARY NO.
APPLICATION SAUBMI/yTTAL DATE
1y I "'
OWNERS NAM' PHONE:
CONTRACTOR'S NAME: LIC NO:
N/C
CONTROLN
'CDENGINEER: LIC NO:
AD RBS:
�tCUI
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'
PERMIT ISSUANCE.
� � � O
LICENSED CONTRACTOR'S DECLARATION
Ihcrebyafdrnibat l am licensed mmc,p.viubnsof Chaptnr9(commendng with
amaNpofeDlvisian3nflheBusinessGnpJof�Yliceneisin
fricund
APPLIANCES - RESIDENTIAL
PANELS
100 DESCRIPTION
fall effc. (JJ
use Cl Lic.#
V" Commaor
UP'f0200 AMPS
rIr
- 1 AMPS
le
ARCHITT:CTS DECLARATION
]understand yplunsshullha used as public records.
SQ. FT. FLOOR AREA
�eo
$/SQ. FT.
OVER I000AMPS
OVER
SIGNS ELECTRICAL
Licensed Professional '
OWNER -BUILDER DECLARATION
SPP.CIAI. CIRCUIT/MISC.
1 hereby a[flrm dun I am exempt from me Contmotods License Law Icor the
"
-
TEMP. METER OR POLE INST.
f ng reason (Section 703LS,,r,lar, and Pro orcounry
demob h, m m mr.n
whish requires Warner, permit to conavaa, alter, Imforsu Jem.it 1 fi repair arty structure
1hirl,
permittofileese statement
itscensed....sorIoniarhovisios
POWER DEVICES -
(done
afraid Co La
9 (. bo lu licensed r Sects l Ionia, ).visions afraid Contractors License Law (Chapter
9 Sof the and Code)
SWIMMING POOL ELECTRIC
VAhIIAT
or that he exempt amfon90a0)he basislon
ed exemption. .Any viols
Sectioholscx bymy.p,lixaand WebasifitmpPs for the allegedaxemant to civil )malty of
Section 7031.5 by any npplicnn[fnrapermit subjects the applicantmacivil penalty of
�/
l L��i 1 L �"!��
V
OUILE'I'S - SWI TCHES-FIXTURES
not more shim five hundred dollars($500).
❑ I,asownerofthepropedy, ormyemployeeswinh wages aslheinolecompensution,
NBW RESIDENTIAL ELECIR _9Q. PT.
STORIES
TYPE CONSTRUCTION
will do the work,.rd lhestrumure is nal innendedorOffered forsale(Sec.704q Business
and Prrfessimen Code: The Conrraators License Law does not apply m an owner of
properly wbnbuildsorimpmvesrhe rain, and whodoes such work himeelforlhroughhis
p.cemwithin nemen
err, 1 dedthat such im t t't ded oroffered foruale. If,
OCC. GROUP
RES. UNITS
TOTAL:
the
however,gill building arImprovement issold withinoneyear or improve
omm efor[urpose of
builder will have the burden of proving that he did not build or imprma for purpose of
QTY. PLUMBINGPERMIT FEE
sal,),
11l,ns eroftheproity,amexclusivelycennmedetingwimiic.sConmaanorsm
pc
FLOOD ZONE
APN
construct me project (Sac. 7044, Business and Professions Code:) The Condador's
Liwnsel.owdoes not upplyman owneroPpmpeny whobuids orimpmvea lbomon,nnd,
PERMIT ISSUANCE
wlmcomracts for such projects with a conhacmr(s) licensed pursuant to the Convector's'
Licene Law.
-
ALTER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. B & P C for this reason
BACK FLOW PROTECT, DEVICE
OUTSIDE FEES
SANITARY Y N
RECHIPTOf
Owner Dano
DRAINS - FLOORROOFAREACOND.
, , ,
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
J❑ I hereby affirm that l have a certificate ofeansent to self -insure, or a certificate of
Workers'Cnmpenvalinn lnsecancemacerified copy 0em.r. Xec. 3800, Lab C.) which
covers all employee's under this permit. -
Policy #
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT#
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
any
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK PRE
citified copy is hereby famished
GREASE/INDUS'1'RL WASTE INTERCEPTOR
GRADING FEE
Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20011'.
ENERGY FEE
(This section need not tie completed Him permit is foroachundted dollars($I00)
orlesa)
WATER HEATER WNIrEr ELECTR
Iri,oifytbat inure performnnceof the work for which this permit isnamed. labor
not employ any pecan in any manner so as m become subject no he Workeis'
PAID
WATER SYSTEM/TREATING
Compensation Lawsof Califordir Date
MAY Receipt#
Applicant
NOTICETO APPLICANT: If, after making this Cedificamaf Exemption, you should
NEWRESIDENTIALPLMB. SQ.Fr.
'TOTAL:
become subject to the Worker's Compensation provisions of rhe Labor Code, you must
fnrhwith comply with such provisioru ar ibis permit shall he deemed revoked.
BUIL F
SEI E 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a instruction lending agency far the perf ion acre of
the work for which this permit is issued(Sec. 3097, Civ. C.)
'TOTAL:
EL 9'RIC FE
Landar's Name
QTY. MFC14ANICAL PERMIT
MB G F.E
Lenders Address
1 certify ]hat 1 have read this application wd state that the above information is
enmecl. I agree to comply with all city and county ordinances and state lawsmlating to
PERMITISSUANCB
IIANI AL PEE
building construction, and hereby authorize representatives ofthls city to enter upon the
above-mentioned propery for inspection purposes.
ALTER OR ADD TO MECH.
ST CTION TAX
(We) agre indemnify an keep Formless the City of Cupertino against
-
liabilities,jud cal anus anrexpens whicM1 mayinar weyaccrucimm sl,.n City
AIR HANDLING UNIT (T010,000 CFM)
V
onsequen of a granting of thi emit.
AIR HANDLING UNIT (OVER I(1,000 CFM)
EXHAUST HOOD(W/DUCT)
D
goal.. of Appli.m/Contract r Dale
HEATING UNIT(TO 100,000BTU)
-
HAZARDOUS MATERIALS DISCLOSURE
Reeipt#
hanWill Ne the Cupertino u icipal Code, gamer 2, and to Health ad Saeed
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Health unJ Safety
I]EATING UNIT(OVER 100,000 BIG) "
VENTILATION FAN (SINGLE RESHO
Cale, Section 25532(e)'f
Cl Yes ❑ No
BOILER-COMP(3HPOR Ia0,0a0 BTU)
PISSUANCEIPAID
IS 1 y
Will the vpplicnumrfummbui 1pmontmality sanagement
nBay
BOILER-COMP(OVER IOO,00)BTU)
A
I:hazardous nlr wnmminwts as defined by the Boy A. Air Quality Management
definedby the
r DlsvlcrR
,
❑Yes 1:1 so
NEW RESIDENTIAL MECH. SQ.FL
a
DEC1 1992
1 have read the hazurdous materials requirearients under Chapter 6,95 of the
{�
California Health A, Safety Code, Sections 25505,25533 and 25534. I understand Nal
if the buildingdoes cut currentlyhaveatenan,don it is my responsibility to imbythe
IIT Ur Wer -
- -
ccul am of the requirements which must be met prior to issuance of a Certificate of
_
Occupancy.
ISSUED BY: _ V'- #'J
Owner or awhoriaJ ngem Date
TOTAL:
OFFICE