24662 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL UING-KLL1L GkGCAL PERMIT NO, 2 4 ^{V� 2
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MRCNANICAI' 'LJ LI�J L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESSw: SANITARY NO. APPLICATIONNSSUUBBMTTALDATE
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"Y S M CONTR N ME
NfC CONTkOL#
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TECTIENGINEER: LIC NO: ADDRESS: ❑
CT: PHONE: TY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BL ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALIOB D[$CRIPIIO
hereby affirm mmlamlicensW underprovisionaofCheprer9(commencing with f �JW7000).(Division 3 ofthe Business and Professions Code.and my licenx is in PANELSe=nd of=l, q /z�r 201.1000 AMPS `e Clas7 Lic.p �VV UPT0200AMPS
Co.hecmrARCHITECT'S DECLARATION S .Ff. OOR AREA $/SQ.FT.
understand my plans shall be used m public records, OVER1000AMPS SIGNS ELECTRICA
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. i� it Ia
u13 LL F' I hereby offinn that 1 am exempt from me Coinsurers Licenx Law for the V L
l
gfollowing rcama.(Section 7W 1.5,Business and Professions Cade:Any city or emmy TEMP.METER OR POLE I
Oy which requires a permit to conswct,alter,improve,demolish,or repair any structure
a7 Palms,it.issuance,olaorryuires me opplieantf...th Permit o file sai'mol atatcmem POWER DEVICES E
ay 0 shat he is licensed pursuant to the provisions of the Contractors License Law(Chapter
de9(commencing with Section 701RE)of Division 3 ofthe Business and Professions Cade) SWIMMINGPOOI AIMIC w VALUATI
�^y
or he is exempt therefrom and the basis for the alleged exemption.Any violation of OIffLETSSWITCHFS.FIXTURES a / �#pk�
�4 Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of i�'�{J
not mom Nen five hundred dollars($500). NEW RESIDEM7AL ELECIR S .
❑ I,its owncroftheproperty,ormyemployees with wageastheirsolecompereation, QFT. STORIES TYPECONS RUCTION
a will duthewmk,and thedruaurc i...timendedoroffaWfo...le(SecJ044,Dusinus
and Professions Cede:The Convacrer s License Law doss not apply to an owner of
property whobuildsorimpmvesthereoa,and whodoessuch work himselformrough his OCC.GROUP RES.UNITS
ownemployee,Providcdthat such impmvememss snte
ot inndedorofferdforsale.If,
however,the building or improvement is sold within one year afcompletion,the owner
builder will have the burden of that he did not build or improve for f TOTAL'
proving p pugsoxo
'EI QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Loao a #reject(Sm.eny. .Business
aycorofessi ns C licensed Contractor's
,
construct the project(Sm.oano nerofp and Professions Cade:)Improver
thereon,
PERMITISSUANCE
License Law d,esnotapply mnnowner n propertywho builds orimprovesthereon,and
whonse Lads forsuch projxta wins aconuactor(s)licensed Wrsuanumhe Contrxmr's
License Law. ALTER-GRAIN&VENT-WATER(PA) FEE SUMMARY
❑ i am exempt under Sec. ,B&P C for this reazon IDE .ES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Data RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑Wc Iheabyaffirromm l have.certifcate,fconent foul(-insure,ora cenifie.teof FIXTURES PER TRAP RECEIP`F#
orken.'Cnmpensation losumaceor semilied e.pymerc,f(Sm.3800,Lab C.)which PARK FEE Y N
coven 111 1 yy:k ft i - - RLCEIPfN
Policy# VV ✓ GAS-G.SYSTEM-I INC.40UTLCfS BUILDING DIVISION FEES
C y —9 �4 rQr 'GAS-EA.SYSTEM-OVER O(EA) PLANCt1ECK EEB
'eni and copy is hereby fumi4hed.
Certified copy is filed with the city inspection division. GREASF(INDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneednot be completed ifine permit is intone hundred dollen(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I mnifythat irthe perftermance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
of employ any penton in any manner so as to become subject to the Workers' PAID
Z n,pacation Lawsof Califomia. Date WATER SYSTIPWREATING D.te Receipt#
Applicant
Z n NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.Ff. TOTAL:
(q becwne.Ajod to me Workers Compensation provisions of the labor Cade,you mon
4iothwith comply with such Provisions or ibis permit shall be deemed revoked BUILDING FEE //s'
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
.�1. z I hereby aff that hem is o construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
pLender's Name PLUMBING PEE
F' Lender.Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and stare thin the above information is MECHANICALFEE
P. correct.lagrte to comply with all city and county ordinances and stale Iowa relating to PERMIT ISSUANCE
�.' h building construction,and hereby authorise mprcxmtivesofthis city to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and kap harmless the City of Cuperfino against
liahilitim,pelgroades esband expenses wh' may in any way xcmeegainstxid City AIR HANDLING UNIT(TO I0,"CFM)
in comes. of Eng of this pe
AIR HANDLING UNIT(OVER 10.011)CFM)
ig mart
id'Als,ficrouiffixtruchis, Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
i Will she applicant or future building occupant store or handle hazamous muteftl HEATING UNIT(OVE0.100,000 BTU) AL:
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 255324)?
11 Yes 13 No VENTILATION FAN(SINGLE RESID) L
T ISSUANCE DATE
W0l theapplicantorfuture buildingoccvpantuxequipmem ordevice whichemit BOILER-COMP(3HP OR 100,000 BTU)air cantnminants as defined by the Bay Area Air Quality Management - BOILER-COMP(OVER For,"BTU)
v cR
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. PA I
I have sad the hazamous materials requirements under Chapter 6.95 of the I e�
CalifoMa Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that VH ` .a,
ifine building docs not currently have a tenant,that it is my responsibility to notify me p / 19
occupant of the req,iremems which must be met prior to issuance of.Certificate of C/Y s.y�a1/
Occupancy. / Of-
Owner or authorized agent Date TOTAL: . ISSUED BY:
OFFICE