24628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 24628
BUILDIN ADDRESS:/per SANITARY NO. APPLICATIONSUBMITTALBA'ff
r5/ UNIT# LOT# jyLj4.k
/
OWowBS'NAME: PHONE: CONTRA TOR'S NAME: LIC NO: N/C CONTROL#-�
Z O I2 .ou
RCHITECDEN INE LIC NO: ADDRESS:
I P Ell I(7A ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOBD CRIPI'ION
V 002 IM17Wygmf Dr,is O amliaensedinss and Professions
Chapter and mmemcingwhh � `�
{�00 Section]000)of Division 3 of the Business and Professions Code,end my license is in PANELS
yuu full PoreeandeffeoL�
4FLicense Class Lic.# UPT02MAMPS
y=y Date Contractor. 201-1000 AMPS
zcO ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FI'�OOR S/SQ.FT.
O Z,.-G 1 undersand my plans shall be used as public records.
IN
rr Fp ,
z Lsensrd Professional SIGNS ELECTRICAL
CG OWNER-BUILDER DECLARATION SPECIAL CUICUIOMISO
agSOaU I hereby affirm that 1 am exempt from the Contractor's License law for the Y
uF.+3Orhil following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. V
C�y.Q] whichrequiresa Permit construct,alter,improve,demolish,or repair any structure
?��a� prior to its issuance,also requires the applicant for such Permit to fi It a signed statement POWER DEVICES
ay q that he is licensed amount to the Provisions of the Contractor's License Law(Chapter
Xcc9(commencing with Section 7")of Division 3 of Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
Wy 2, or that be is exempt herefrom and the hmis for the alleged exemption.Any violation of
�r m
Section S by any applicant fora ma,uhrOx the applicanfOUTLETS a civil penalty of SWITCHES-FIXTURES
not m than flue hundred dollars(3500}
penes NEW RESIDENTIALELECTR S FT.
yp 1, s k,aDthe'In rty,ormyempenshol wofwed failrei(See.7rm ties, 0' STORIES TYPE CONSTRUCTION
n .1nethcwrs andthestoC atinctm's mndese Law does no,apply to an Business
J arty v hiobo Cade:YTe Contraction's License Law aces not apply to an owner of
pmpertywhobnitdsorimprovesthereon,and who aressuch mimenarthimselforthroughhis
wnever thebu,p ing or improvement
is
sin neyeardedmmffered fm.witeIf. WC.GROUP RES.UNITS
however,the building or Improvement is hath within aneyear of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
eele).
❑ L as awnmofthepmperty,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onment the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply to an owner ofpropery who builds or improves thereon,and PERMIT ISSUANCE
whocantracts forsuch projects with acontractor(s)licensed pursuant to the Contractor's ALTER Law. WATER(E/O FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE - UU I NIUE IEbs
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ Ihereby affirm that l have a certificate ofecrsentto sel6insurgara ormificmeof FIXTURES�PER TRAP RECEIPT#
Workem'CompensationInsurance ter a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covars all employee's under this permit. GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ Cmifedcopy ie hereby fumishetl. GAS�EA.SYSTEM-OVER 4 EA) PLANCHECK FEE
❑ Cenifed copy is fled with the city inspemion division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKER
COMPENSATION INSURANCE S' GREASE TRAP SOILS FEE
(Thisaectionneedirm becompleted ifthepermit is for one bundreddollars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensation Law.of Celifimm. Date WATER SYSTEMITREATING
Applicant Data Receiptb
Q O
NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,yuushould NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
4 become subject to the Workers Compensation provisions of the Labor Code,you mast -
jforthwith comply with such provisiom or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is s construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
ULenders Name PLUMBING FEE
Lend Ic Address QTY. MECHANICAL PERMIT FEE
LTI I certify that 1 have read this application end state that the above infommrion is MECHANICAL FEE
orect lagreemcomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
V) building construction,and hereby authorise representatives ofthls city to enter upon'he
U 7 above-mentioned properly for inspection purposes. I ALTER OR ADD TO MECH. CONSTRUCTION TAX
•^� (We)agree to save.indemnify and keep harmless the City of Cupertino against
liabilities,judgmema,mhts endexpenses whichmay in any way accrues einst said City AIR HANDLING UNIT(TO 10,000 CFM)
in can ft i agingof this -
�� AIR HANDLING UNIT(OVER 10,(10)CFM)
ature fA plican4Cmdomo.r �,ro EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IDgOW BTU) Date Receipt It
WI 11 the applicant or future building occupant sort or handle bounders material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Heohh and Safety HEATING UNIT(OVER 100,0110 BTU) TOTAL:
Code,Section 25532(d?
❑Yes ❑No VENTILATION FAN(SINGLE RESIED
Will theapplicanmrfuturebuilding mccupamuse equipmentordeviceawhich emit BOILER-COMP(3HP OR 1W,g0(0 BTU)
ISSUANCE DATE
hmandous air commminams as defiaeJ by the Hay Area Air Quality Management
JistriclY BOILER-COMP(OV LR 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A B T
I have read the hevurdous materials requirements under Chapter 6.95 of the Iy� 6J
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that Nf.I4i —is DEC 17
ifthe ccupanilofthe requireng does not ments
whit muste a a et t it prig 0 issuance iota Cenmify the 1992
occupant of the rcyuirememe which must be met prior to issuance of a Certificate of yyL
Occupancy.
Owner or aatlanderd agentpate 011 Y Ur L``rT�:JyII
O �I ISSUED BY: r{I�s/�"•
OFFICE