24926 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILD ING-F.ECHA ICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIN ECT IDENTIFICATION
BUIIAING PROJECT IBENTIFICATION
BC NGA/DDDRESS:�] `n� '�/� J �J,r / SANITARY NO. APPLICATION SUBMI ITALL DATE
1 Z / / e x--�('v UNIT# LOT �Q �
,,Jr,yell OWN�'gGt�AME: PHONE: CONT CI'OR'S NAME: LIC NO: N/CF CONTROL#
L U zs3-6537
CHITECT/ENGINEER: LIC NO: ADORES$:, ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG fIk,ECr PLUMB MF.CH
PERMIT ISSUANCE I17L�]\�. � /tU�l�y
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb ffitm that l am licensed under p (commencing with JOB DESCRIPTION•
❑oC2 Yu provisions o[Cha mr9(wmmenoln
1400 Seetien 2000)of Division3 of the Businen,and Profasslons Code,and mylicwse is In PANELS
y.� f reeandefPoe� 07�
< manse Cl Lia# UPT02MAMPS
vFiQy Date Contracmr /7p— 201.1000 AMPS I
Fy$M ARCHITECTS DECLARATION FL AREA E/SQ.Cr.
OZ
y,C�, 1 understand my plans shall be used as public records. OVER 1000 AMPS -
rr4Ytw! SIGNS ELECTRICAL �p � 7 J ER
9 C W
Lot enseA Processional
OWNER-BUILd to..h CmarizON SPECIAL CIRCUIT/MISC.
WWp,04 cn I hereby n.(Sn that I um exempt from the Contractors License Law fur the
3p.m following reasoa(Senion 2031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE NST. DATE
I�1 01 which requires a p—it be realan ct,cher,improve,demolish,or repair any convince
rm 2+Yprior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
K GO that he is licensed pursuant to the pimer rens of the Contractor's License Law(Chapter
o.qo T 9(commencing with Section]00cpot Division 3oflhe Business and Professions Coate) SWIMMING POOL ELECTRIC VALIIAI'IOpLM
XWerr
�rn or that he is exempt therefrom and the basis for the alleged exemption.Any violation of /11�
Y Seetion 2031.5 by any applicant on. rm
ora peit subjects thm e applicant a civil penOUTLETS-SWITCHES-FIXTURES
ally of 06
� G
contain than foe hundred dollars(E500). NEW RESIDENTIALELECTR S
❑ I,osownemfthepropeny,ormyempinyees with wagesastheirsnlecumpensntion, QFC STORIES TYPE CONSTRUCTION
m will dothewofk,and thestruome isnot imendedoroffereAforsale(Site 201 Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work himself or through his
employees,provided Nat such improvements we net intwdedcroffemd forsale.If, OCC.GROUP RES.UNITS
however,the building orimprovemenl is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowner oflhe property,am exclusively contracting with licensed commeaccom QTY. PLUMBING PERMIT FEE FLOOD_ZONE APN
comma the Project(Sec.7044,Business and Professions Cade)The Contractor's
License Law does not apply to anownwofploparty whobuildsorimpomew thereon,and PERMIT ISSUANCE
who coolowtv'orsuch projects 01h.cwtoraros)licensed purcuant to the Cwharcmr's' ALTER CA FEE SUMMARY
LicenseLaw. (' )
❑ um exempt under Sec. ,B&P C for This reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
I4-Owner - Dale DRAINS-FLOORBOOPAREACOND. RECEIPT#
WORKMAN COMPENSATION DECRATION SCHOOL TAX YN
WIth byaffont that l have a coniflcate ofconcenl LA , , , .loself-insure,ora certifieamof FIXTURES-PER TRAP RECEIPT#
ilke os Compensation Insurance or a certified copy thereof(Ser.3500,Lab C.)which PARK FEE Y N
�covere al l employee's under this pentyl. GAS-EA.SYSTEM_ INC.4 OUTLETS RECEIPT'#
-. Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA)
❑ Certified copy is hereby famished PLANCHECK FEE
❑ CeniIred copy is Filed Malaise city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Him permit is for one hundred dollars p$HFd SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER WNENT/F.LECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Culifomia. Date WATER SYSTEMUREATING Dae Receipt#
Q Z Applicant
Z 0 NOTICE TO APPLICANT:If,-foal making this Cenificae of Exemption,your should NEW RESIDENT IAL PUSH. SQ.FT. TOTAL:
V) become subject to the Worker's Compensation provisions of the Labor Code,you must
� , firth lith comply with such provisions or his permit shall be deemed revoked BUILDING FEE �r
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a consortium lending agency fr,he performance of TOTAL: ELECTRIC FEE
U the work for which this Perm,is issued(Sec.3092,Civ.CJ
lk. Lender's Name PLUMBING FEELeader,Address QTY. MECHANICAL PERMIT FEE
U U 1 cavity that l have read this application and scale that the above information is '
correct.I mom comply withal]city-ndcnunly ordinances and state bawsrelutingm PERMIT ISSUANCE MECHANICAL FEE
buildia,rce,lruclion,and hereby awhodmm,resenmtivea oflhls city m warr upon lhe
CONSTRUCTION TAX
U ,Z above-mentioned properly fH.or ins cation purposes. ALTERORADDTOMEC
(We)agree m save nd keep harmless the City of Cu,wim against
liahilities.jodg nt sts ndexpen. swhich y any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
inconsequence flto ng oftbi permit _
AIR HANDLING UNIT(OVER 10,000 CPM)
Signa or Applicsi Colnraaor Dam EXHAUST HOOD OODUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOQOW BTU) Dam Receipt#
Will the ppliant or furore building nrcupanlamre or handle haaavlous mamrial HEATING UNIT(OVER 100,000 BI U) TOTAL:
Is defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safely
Cade,Section 25532(a)2
❑Yes El No VENTILATION FAN(SINGLE RESID)
Will rhea licentorfumre buildin fusee ui BOILER-COMP(3HP OR 100,000 BTU)
ISSUANCE DATE
pP &ocoupan 9 pmenmrdevlws which emir
zadous air comaminants ns defined by the Bay Area Air Quality Management p1 p '
soicl2
BOILER-COMP(OVER 100,000 BTU) P' A
❑Ycs ❑No NEW RESIDENTIAL MECIL SQ,FT.
T[cave read the hazardous materials requirements under Chapter 6.95 of the WAR 3 0 1993
Califumin I leehh&Safmy Cade,Sections 25505,2553]and 25534. 1 rndenarro that
if th ream o the requirements
which
must this et prior
my issuance
oility Certificate
the /� 1(I
Occupant of the regoiremems which must be met prior to issuance of a Cenifi<ate of V I I I lA' V UI G!1
Occupancy.
-�'_ -
Owner or autborixed-gem Date 3 ISSUED BY:
OFFICE