24707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B alH G-ELECT PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /'� ^4 0
BUILDING PROJECT IDENTIFICATION G
BUILDING A/D�DRESS: ••awk SANITARY NO. APPI.ICATION SUBMITTAL DATE
v�� V Tm UNIT# LOTa Ir Jlw/!{y
OW PHONE: CO R'S NAME: CN ` �� 6
N/C CONTROLp
•ARCHITTiCf/ENGI At: LIC NO: ADD %D ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECIARATION APPLIANCES-RESIDENTIAL -LOB DESCRIPTION I hereby afflor Rat l ma licensed under previsions ofChaprer 9(commencing with
ts100 Section]000)of Di 'cion eBusiness and Professions Cole,and my license is in PANELS �A Ar�,�g• I�
feu mree arta eD
Lic sect Li..N .2 22D UPT02WAMPS
rFir 4�' a Comrecmr 201-I000 AMPS
Fye ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
z0 z-I] 1 u dersmnd my plans shall be used as public records. OVP.R 1000 AMPS
Fea(;W SIGNS h
E 14
C
Licensed Professional
SKC OWNER-BUILDER DECLARATION SP CIA 1 T/MISC. Alt
O a V I hereby affirm that 1 am exempt form the Contractors License Law'a ..
y13LLy following mason.(Section]031.5,Business and professions Code:Any city or county .RORPGLF. ST.
�:ISo5 which requires a pandit to construct,alter,improve,demolish,or repair any structure
12� 2 OCT m its issuance,also requires ma
the applicant for such penman rite asigned statement .R DEVICES
6HO that he is licensed pursuant o the provisions offle Contrnnors License Law(Chapter SWIMMING POOL EI.
aaoK 9(commencing with Section]Of10)of 0ivisinn 3nfthe Business and Pmfexsion Code) VALUATIp2' .
m�'^y er that he is exempt therefrom and the basis for the alleged exemption.Any violation of 011'11LT5-SWITCHIiS-FIXTURES T®
(rza
Section 7031.5 by sayapplieant far apeooitsuijectpp
s theulicaut civil penalty of
� C
nor more than five hundred dollars(5500). NEW RFSIDF.NTIALELECIit _}_ _
K ❑ I,azownerofthepropmy,ormyemployeeswithwagesasthelrsolecomp nsation, I TORS 'TYPE CONSTRUCI30N
y willdothework,and thestrunureisnm Wendedoroffered for isle(Sce.J(144,Business
and Professions Code:TM1e Contractors License Law does not apply m an owner of u T E
propertywhobuildsorimproves the ean.snd wbodeas such workhimulfomluough his p V
own employees,Provided that such improvementsare not intended reoffered forsale.If, OUP RFS.UNITS
however,the buildingorimprovement is sold within one yearo(completion,the owner- TOT 1J
builder will have the burden of proving that he did not build or improve for purpose of
e°1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,ct e e pmje h(Sec. 0PL,Business
s s and ore Professions
Cod en a Contctorsto
dense the pmjnot(Sec.]044,Business and Profession Code:)The Contractor's
Licenutawdaes such
apply ms withamffnoprsy who
sed pumimprova theman, PERMIT ISSUANCE
whocontractsfor such projects withucentramogs)littnud pursuanuothe Contndurs ALTER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC fm this o anon BACK MOW PROTECT.DEVICE T OF.FEP
SANITARY YN_
Owner Date RECBIPT a
WORKMAN COMPENSATION DECLARATION DRAINS.FLOOR.ROOF,AREA,GOND. SCHOOLTAX Y N
°❑ I hereby affirm that l have a certificate efcousenno self-insure,or a onsificateof RECEIPT#
FIXTURES-PER TRAP
•Wnrkers'Compnutien Insurance oracenifiedcopy thereef(Sec.3800,Lab C.)which PARK FEE YN
coven all employee's under this pemtit. GAS-IA.SYSTEM-1 INCA OUTLETS RECEIPT a
Policy# BUILDING DIVISION FEES
C GAS-F.A.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby famished.
❑ Certified copy is filed with Be city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This union read eat h compined ifthe permit is ferone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
nrless.)
I certify that in the perfommnceofthe work forwhich Nis permit is issued,l shall WATER HEATER W/VEM7ELECTR
not employ any person in any manner so as to become subjmt to she Workers PAID
z Compensation Laws of Califomia. Dam WATER SYSTEM/TREATING Data Receipts
Applicant s
O0 NOTICE TO APPLICANT:If,after DENTAL this Certificate of Exemption.you should NEW RESI DENTL PLMB. SQ.FT. TOTAk.
�+ V) become subject to the Worker's Compensation provisions of the Labor Code,you must
7 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE '
Vz Iherebyaffirm that there isaconswctiun lendingagency Porde pedorman.cef TOTAL: ELECTRIC FEF.
O the work far which this Permit is issued(Sat.3097,Civ.CJ
Lenders Name
0 QTY. MECHANICAL PERMIT FEE PLUMBING Fee
Isnd I c Address
L.1 1 certify that 1 have reed this application and ream rhes Rea above informationis MECHANICAL FEE
�" Da cond elagrs To comply with all city and county ordinances antl seam laws relating
m PERMIT ISSUANCE
f-" y building construction,and hereby amhoriu represenusivesofthis city to enter upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We gree m save,i emnify and keep harmless the City of Cupertino a dost
liabiliti ,jtt gmcmv,ens despensu which yknenyw.y eccme gdnst City AIR I IANDLINGUNIT(TO 10000CFM)
incons ethe grn gof thi omit.
AIR HANDLING UNIT(OVER 10,0110 CPM)
Signature.(Appllcun4ConoactoT ate EXHAUSTHOODOVIDUCT)
PAID
HAZARDOUS bomb MATERIALS DISCLOSURE
HEATINGUNIT(TO 100,(X0 BTU) Data Recmp#
Will the the Cope m future building occupant mare.,handle Herdth a materiel
ss defirteJ by the Cupertino Municipal CNe,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) L:
Code,Section 2553200? VENTILATION PAN(SINGLE R[SID)
ID Yes 11 No g
ISSUANCE DATE
Will theapplimtorfutumbildingoccupantuseequipment mdeviceswhichemit BOILER-COMP IMP OR 100,000 BTU) Rf p Y9 D
.hmv n atartims air comaminadefiaed by the Bay Area Air Quality Managemeus BOILER-COMP(OVER 100,0100 BTU) I(�
District? epnnr 1nn9
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. �I9,Y �@ /JDJ
1 have read the haaardeus materials mqu damns under Chapter 6.95 of the CITY Vr II 199
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that LUrC
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prim n issuance of s Cenifiote of Ii��J/l
Occupancy.
Owner or amherixW agent Date TOTAL: ISSUED BY:
OFFICE