24772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICA I. PERMITNO. a�
APPLICATION/PERMIT PLUMBING.MECHANICAL •LJ •LJ
BUILDING DIVISION BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADORE illisk_e / hk_ SANITARY NO. APPLICATION SUBMITTALDAII!
7- ��OO r(l` UNIT LOT
OWNERS NAMV.: PHONE: CONTRACTOR'S NAME: LIC NO: NUC COM'ROI.a
AVeRFcllvtrlrlrwafG Tao O
•ARCI UI ECI[FNGINEER: LIC NO: ADDRESS: - ❑
4 9CsaF+ 'rg4lol4
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDP ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARA]']ON APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Q=Z Ihereby affirmthat l am licensed underprovisions of CTepier9(commencing with
POO Section 7")of Division 3ofthe Business and Professions Code,and my license is in PANELSold- r(./�� /
FF<Zt Ideefallfmrise ClasssendeB Lic.p6333a° UPT03IXIAMPSl�C�l�� �` 1
y Q y Dam_kn.l n n_ Cmaramor.(glq�g(pgFJY�g.�aN i(,Qlfj. 201-1000 AMPS
F-y �•+a�' ARCIII'TECTS DECLARATION SQ.FT.FLOOR AREA $15Q.FT
ZOy�' OVER 10(X1 AMPS A ■
OZ-O IunJemm�d my plans shall be used as public records.
I=4j SIGNS BLGICA}—
CQCQ Licensed Professional
NWU OWNER-BUILDER DECLARATION SPECIAL CIR UIT SQ
P�0 1 hereby affirm that 1 am exempt from the Contractors License Law for the _„ -
m31r.y following reason.(Section]031.5,Business and Professions Code:Any city or county TIME.!AFTER OR ft.i INST.
IS�� whichreyulresapermittoconstruct,alter,improve,demolish.or repair any structure
wry prior to itsissuancqalsorequirestheapplicantforsuchpermitmfileasignedmotionat PoweRDevIFS DATE
m aYM0 that he is licensed pursuannofhe provisions of the Contractors License Low(Chapter
e.cX.o�' 9(commencing with Section Tp0)of Division 3 ofthe Business and Professions Cade) SWIMMING ECTRIC V UATIO�,el
W_m or that he is exempt therefrom and the bmis for the alleged exemption.Any violation of
Q Section 7031 51, anyupplicant for aPermit subjects the applicanttoocivil pmany of OUTLETS-SWITCHES-FIXTURES
O not more than Eve hundrvJ dollars($500).
o ❑ LusowncrOfthe properly,ormyempinyaswithwegwastheireolecomperuation, NEW RESIDENTIAL RLEMR _SQ.PI'. STORIES TYPECONSTRUCTION
x300 will Bothe work,ancithe structure isnot intended.,offeresd for sal e(Sec.]044,Businas
and Professions Code:The Contractors License Law does not apply to an owner of
propery,who builds orimproves thereon,and whoduessuchwork himelfor through his OCC.GROUP RES.UNITS
own employees,providedthatsuch improvemetnsmarotintendedoroffered forsals.If,
however,the building or improvement is sold within one year of completion,the owner-
TOTAL:
builder will have the burden ol proving that he did not build or improve for.purpose.f
ss1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑commoner
the poOftt,(Seeprony,1, "elusivelyand contracting with Th Cont,torsm
.cora the project apply ly ono Business and Professions oramp The Chemo ,and PERMIT ISSUANCE
Licensetrawdforsucappjects with
acon prOpeny whnbuildsorimt tothe ontracand
Licenseho Law,
Gorsuch projecmwitbaconhaanr(a)licenxdpursuam lathe Contractors ALTER License Law. FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICETSIDE FEES
SANI'TARY Y N
Owner Date RECEIPT
• DRAINS-FLOOR,ROOF,AREA,GOND.
ORKMAN COMPENSATION DECLARATION SCHOOL'TAX Y
1herebyaffiWrmthat 1have a oracerti econtenter uf(Se .3 or Lab C.)which
RECEIPTM
FIXTURES-PER TRAP
Workers Compensation Insurance nracmified copy thereof(Sec.381NJ,Lab CJ whicM1 PARK PEE YN
vers all employ e's t ry RECEIPT a
la ' ^ GAS-IiA.SYSTEM-]INC.S OUTLETS BUILDING DIVISION FEES
Policy p f.A'
Company ��rysr.+ GAS-IiA.SYSTEM OVER 4(EA) PLANCHECK FF£
❑ Certified copy is hereby umishcd.
❑ Certified copy is filed with the city inspection division. GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRESB'I'RAP SOILS FEE
COMPFNSATION INSURANCE
(Tbisseaiar needmt be completed ifthe permit is harem hundred dollars($100J SEWER-SANITARY-STORM E.20kn. ENERGY FEE
or less.)
I certify that in the Performance of the work for which this Permit is issued,l shall WATER HEATER WIVEN71ELECTR
not employ tiny person in any manner so as to become subject to the Workers PAID
Compensation Luwsof Celdomia. Date WATER SYSTEM/TREATING Date Reeciptis
O Z Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PIMB. SQ,FT. TOTAL:
to become subject o the Workers Compensation provisions of the labor Code,you muss
? forthwith comply with such provisions aphis permit shall be,deemed revoked. BUILDING FEE - BO
Q' CONSTRUCTION LENDING AGENCY SEISMIC FEE ISD
1 hereby affirm that there is a construction lending agency for the performance of
V Q the work which this permit is issued(See.3097,Civ.CJ 'TOTAL: ELECTRIC FEE
Lender's Name
OU Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LU1 certify that I have read this application and state that the above information is
roomer.I.greetocomplywithallcityandcountymVinoncesandsmtelawsrelatingto PERMIT ISSUANCE MECHANICALME
�t y buildiagconstmction,and hereby authorize representativeso(this city to enternpon the CONSTRUCTION TAX
U 7 above-memioneJ property far inspection purposes, ALTER OR ADDTO M1iCH,
G (We)agree to save,indemnify and keep him less Be City of Cupertino against
Iiabilities,judgmenu,rnsts and expenses which may in anyway uccrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
seg f.wgmnting (this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
5ig RE,uno ppman V t7i'llitarts - Data EXI fAUS"f 1 IOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,000 BTU) Dam ReceiptN
Will the applicant or future building occupant store or handle havNous material HEATING UNIT(OVER IOO,tXlO BTU) TOTAL:
as def red by the Cupertino Muyyyrrrput Code,Chapter 9.12,and the Health and Safety
Code,Section 0 Yet, )] / VENTILATION FAN(SINGLE RESID)
❑Yes Na
BOILER-COMP QHP OR 100,(X10 BTU) ISSUANCE DATE
• Willtheapplimntarfmuubuildingac the Bay Arm menmrality Management
PAID
hazardous air conmminanH mo fined by the Boy Arta Air Qualify Management BOILER-CGMP(OVEIt IOO,gp BTU)
Dis al
CI Yes NEW RESIDENTIAL MECH.—SQ.FT, 1 s �p�9a�y�
I have read the hazardous materials rcyuiremems under Chapter 6.95 of the California I lealth&Safety Code,Sections 25505,25533 and 25534. 1 understand that FEBV
if the building does not currently have a tenant,that it is my responsibility to notify the V N(Grl I BVV
accu quimm 1'chmust h met prior to issuance of a Ccnificac of Ct I y Ur
CKS
Owneroruuf olsgem Dace TOTAL: ISSUED BY: •' f' `aw
OFFICE