24791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I i-ELEC I RICAL PERMIT NO.
AL
BUILDING DIVISION APPLICATION/PERMIT PING PRNO C I IDENTI ICA 24791
BUILDING PROJECT IUENTIFIC.ATION '
BUILDING ADDRESS: "SANITARY NO. APPLICATION SUBMITTAL DATE
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CSI UNIT# LOTH
(\ a,+u W L. r PH E: — COQ' i.CTOR'SNA14 : ^ IC 00.� NIC
CONTROLq
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RCHITECT/ENGINEER: LIC NO: ADDRESS: O `h ❑
+y G') ._ s
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/ B ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONT under M'SDnsof Ch err gppLIANCES-RESIDENTIAL )OB DESCRIPTION
pp�Z Thereby aflimBOTH licensed uACTORvisDECL DECLARATION
'�J
VJ00 Section 9000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS /��.bu-1 CA,moVY /h
t t full forceandeff ,4 b 3 UP T0200 AMPS -
GZW Do, lass Lic.p ould-eRsr,�! z
y�N .Date Commo�IVa� 201-1000 AMPS CK liL
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
CZ--M I understand my plans shall be used as public records.
F1-cii SIGNS ELECTRICAL - -
QQ��44 J Licensed Professlmnal
Lyw6 OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/MISC.
0'U I hereby affirm that I am exempt from the Contractor's License Law for the
3 m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
; which requires.permit lm construct,cher,improve,demolish.orrepair nay sweet¢ " I
of,to
prior to its issuance;alsmrequires the applicant forsuch Permit file asigned statement POWERDEVICES
� q0 that he is licensed purcusnuo the provisions ofthe Contractor's License Law(Chapter UA 1
a op' 9(commemeng with Section]000)of Division 3 of the Businessend Professions Code) SWIMMING POOL ELECTRI V CATION_
7031 b therefrI hot for
the Permit subjects thedexcmprioo.Anylpenamn of OUTLETS-SWITCHES-FIXTURES ,
QSection 70315 by any applicant forapennit subjects the applicant .civil penalty of 65 / DO
0 nnl more than five hundred dollars($500). NEW RESIDENTIAL ELECTR .
0 CII, asowneroftheprogeny,ormyemploymswithwagesustheirsolecompensation, 5 Q FT. STORIES TYPE CONSTRUCTION
a will do the work,and the strunursisomintendedmidifered farsale(SecJ044,Business /
and Professions Cade:The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon.and who does such work himselfmr through his OCC GROUP RES.UNITS
wnemployees,providecithal such improvementsion nm intendedorofferedforsale.If,
however,the building orimprovement is sold within one yearafcompletion,the owner- TOTAL:
G /y/ builder will have the burden of PrnvinB that he did not build or improve for purpose,of -
D sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ has owner project
pTO(See, My,704 am Business an cmntteaing with de:)The Contractors
ro
keconsrs et the project(Sea onn o Business and y who build Code:)The Conlmctond PERMIT ISSUANCE
License Law does oat aproy to an owner of property who licensed
or improves thereon,and
Lho icense Law.
forsuchprmjecte withacmnvacmr(s)licensed pursunnOo the Contractor's ALTER License Lew. � FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ES
SANITARY .Y N
'Came, - Date DRAINS-PLOOR,ROOF,AMA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
3 I hereby effiim that I have a certifica¢of consent to eelDinsure,or a cerlifca[e of RECEIPT#
FIXTURES-PER TRAP
drkers'Compensarion lnsurun<e mrucertifed copy thereof(Sea]gOq Lab CJ which � PARK FEE Y N
-�. „'�)� hrvere ell emplo kN j/_�D ^ - GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
policy# 7 YJ - BUILDING DIVISION FEES
Company Or zz GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑❑��nified copy is hereby fumlahed.
0(Cenifiedcopy is filed with the city inspection division. - OREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
���� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP I SOILS FEE
COMPENSATIONINSURANCE
(This section need not becompleted ifrhe permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE t
or lose.)
I cenify that in the pertrmarm,of But work for whichdox permit is issued,I shall WATER HEATER W/VENT/ELECTR _
not a ploy any pe son in any manner so as to he oma subject to the Workers PAID
Compensation Lawsof Culifnno. Data WATER SYSTEM/TREATING Date Receipt#
Q ,z Applicant -
Z NOTICE TO APPLICANT:If,Staff making this Cenificam of Exemption,you should NEW RESIDEN TIAL MNIR. SQ.FT. TOTAL:
become subject to the Workers Compensation provisions ofthe Labor Cade,you must -
> forthwith comply with such provisions or this permit shall M deemed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that there is a tom uclion lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
IY �.r Lender's Some -
O FUr Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and state that the above information is
W correct.Ia me to camply with all cit and ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
B Pyhe city representatives
g
building carmoodtirmand herinspeeby ctionpomwesntatives of this city to enter upon the - CONSTRUCfION TAX
V z above-mentioned property for inspection ind purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabiliticaPagmcnte,coslsand expenses which may many way. 1tol'oinsl said City AIR HANDLING UNIT(TO 10,000 CFM)
'a consequence of thir^his permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature air
f IianUC lnf Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupied sen,or handle hazardous material HEATING UNIT( 0 BTU)OVER 100,00 T
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety _
Code.Section 25532(a)? VEN'T'ILATION FAN(SINGLE RFSID) L
Ely. ❑No
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
fir" Will tair correctional,
building by hemae Aa.Aird Quin Management P A i D
zardous air contaminwrs es defined by the Bey Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) H LJ
Dietrid1
i�S r ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. ��� �axJUJUav�
~Ak"'rs 1 have read the hazardous materials requirements under Chapter understand
of the 18
California Health&S.fety Code,Sections 25503,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the ,Cllr ur 1.ur[Alar
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:��
OFFICE