24501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECI RICA[. PRRMII NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MKCHAN'ICAL ^L 4
e OBUILDING PROJF,C1'IDKN'I'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLIICATION SQ[iM�r1/9AL9DATE
OWN- AME.: PHONE: CO ACTOR'S NAME: I.TC NO:
NICCONTROL#
�RC IfTECI'EN,INtim: LICNO: ADDRESS: 1
2a ❑ `
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
OI'/ ^✓� ��ir7 B ELECT PLUMB MECH
!JV PERMIT ISSUANCE ❑ F-1 ❑
LICENSEDCONTRACTOR'SDECLARATIOry App1.1ANCFS-RF.SIDLM'IAL
000 Ihcreby Division 3.f'but Ima alufla under provisions OfChapter9(mmy licame,with TOB DESCRIPTION
MW0 0 Seelitsfarbn9tandef Division Business and Profasiov Code,and mylicenx is in PANELS
Fa Z0 License
Cladcffcet, t
ZW License Class Lie# UP'TO 200AMPS `,�,�a•VxJ
m?y Dau Contractor 201-]"AMPS
¢.Or"za77' ARCHITECTS DECLARATION OVER "AMPS S0.FT.Fl.00R AREA g/gQ.FI'.
OZFW I understand my plans moll beused e5 publicrecords.
Fqy�� --awn loatennotud SIGNS ELECTRICAL
gKxG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
R'OLF 1 hereby affirm that I em exempt from the Cnnwetor's License Lew for the
LLON followingrc;moa(Section 9031.S.Bmmess and Professions Code:Any city nr county TEMP.METE OR POLE INST.
(=�o, which resumes a pewit to construct,alter,improve,demolish,or repair any structure
CaE primmitsissuanca uIs.e,mrsa Neupplicam far such pewiuo file.signedatatement POWER DEVICES
YYII �p in.,he is licensed pumoam to the provisions of the Contrenor's License Law(Chapter
p'Xp� 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC V .TION
W—, or that he's excmpnherefrom and the basis fee restaged exemption.Any vichnionaf
Sect ion]031.5 by any applicant for a peonit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
O nut more than five hunched dollu5(SSod).
W ❑ I,asownerOfthe property,ormyemployttswith wagesustheirsolccompermatioq NEW RESIDENTIALELLCR _SQ.FT. STORIES 'TY PE CONSTRUCTION
a will do the wrk.and the structure isnot intended#roffered forsale(Sec.7044,Business
and Professions Code:The Contractors License law does not apply m an owner of
property whobuilds or improves thereon,and whadoes such work himselforthrough his
nemployces,pmvided thasuch improvememsaenot inumdcdorofferedforxle.If, I n IN n ,.\ tl (pOtGWiQP 0 RES.UNITS
however,the building orimprovement is sold within one yeao(completion,theowner- 'I 1p, A
builder will have the burden of proving that ha did not build or improve for purpose orgFER
TOTAL: W
sale.).
❑ I.mownerofahe Pmprosy,amexdu5ivelycontractingwfthllcensedcontwtomto BING PERMIT WiE J' 0 FIR) Z E #Pry
construct the project(Sec,#044,puniness and Professions Code:)ILe Comemors
License Lawdoesnut apply man ownetofma my who builds orimproves thermmandE
who contracts forsuch projects with acontractor(s)licensed pursuant the Conwaors
License Law. VENT-WATER(EA) MA
❑ 1 am aempt under Sec. ,B&P C for Nis reason O SID ;ES
MCT.DEVICE
Owner Data SANITARY yry
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT'#
❑ IM1ereh friesthstlh.veuttniricate nfroreent mselbinsure,nr.ceniricate of SCHOOLTAX Y N
y FIXTURES-I'F:R TRAP RECEIIT#
cmv ms'Compensation lnsumntt ora ttnlEed copy tM1ercof(Sec.3881,Lab CJ which PARK FEE y ry
uvee.11 employee's under this pewit.
Policy# GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Campy BUILDING DIVISION MIES
nified copy is herebyfummed. GAS-p.SYSTEM-OVER 4(EA)
PLANCRCCK FEL
act copy is riled with the city inspection division. ORIASFE(NDUSTRL WASI'F INTERCEPTOR GRADING FUR
CERTHICATE OF EXFMPr1ON FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE SOILS FEE.
or lana.)
olds section raced not be completed iffn pewit is for one hundred dollars(5100) SEWER-SANITARY-STORM EA.200FT. RNERGY FEE
I certify that in the performance ofthe work for which this pewit is issued,l shall WATER IMA TER W/VENT/HI.ECTR
na employ any perann in my rearrom so ar to become subject to the Warkaaa PAID
Z Compensation lawaof California. Dom WATER SYSI'EMILERATING
0 O Applicant Date Receipt
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.pT.
t" I) become subject a the Workers Compensation provisions ofthe Labor Code,you must T TAG:
forthwith comply with such provisions or this pewit shall be,dremed evoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FET 6
z 1 hereby affirm that them is a construction lending agency for the performance of
U O the work for which this pewit is issued(Sec.309'7,Civ.C.) TOTAL: ELECTRIC
F-a
[.end,,"Name
Ur leader's Address QTY. MECHANICAL PERMIT FEE PL 'EE
1 certify that 1 have eud this application and start that the above information is
correct.I agree to comply with all city and county ordinances and state laws relmingto PERMIT ISSUANCE ECH 'ALFEE
Vh building construction,and hereby authode m1mannawivesofthiscity,to enter upon the
7 aMve-meminned pmpeny for iteave'on purposes, ALTER OR ADD TO MECIL CONSTRUCTION
�-a (We)ogee to save,indemnify and keep harmless the City of CLpeninn against
liabilit'ea,judgments.costs shdeapenxswhich may many way accrueagamot said City AIR HANDLING UNIT CPO I0,"CFM)
Inc co grand of tit.
041
arose e �
AIR HANDLING UNIT(OVER 10,00)CFM)
ignuturo of Ap ontruu � �--Dumb FXfiAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the CLpessam Municipal Code.Chapter 9.12,and the Health and Safety BEATING UNIT(OVER I W,WO BTU) TOTAL:
Code.Section 25532(x))
❑Yes ❑NO VENTILATION FAN(SINGLE RESID)
BOILER-COMP3HPGR IM."BTU ISSUAN DATE
Will tair contaminants
as defining by the
Area equipment es Managemch ent ( j
hvaNnus air contaminants as detinet by the Bay Area Air Quality Mmegement BOILER 100,000BTU)
District^ p y
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. 1P p9 O D
1 have read the hazardous mamrials eyummoods under Chapter 6.95 of the
California building
de&Safety Gdc,Seeman 25.15,t it is and responsibility
I underswnd Not
Hthe building ricesnmmm,currently have intend. it is my responsibility tonotify the IVOtl
occupant of the equircmem which nun be met prior m issuance of.CcniOcate of IV
oemm
pny. Jr 1
Owner or amnanxa agent Dom
TOTAL: ISSUED BY:
BY:
OFFICE