24465 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24465
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAM
Clx ICS NAME: LICNO:
.VR N/C- CONTROL H �
R 1
/E INE LIC N(y.._� ..
CON /� PxoNIFE - BUILDING PERMIT INFO
QTY. FLEC CPERMIT FEE
`C/s(iL ELECT PLUMB MECH
PERMIT ISSUANCE � � ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Cy ffirm
TherebyaibmlamllcensMunderprovlslonsof ChVmr9(e mmcneingwim
P�10 Section 7")of Division 34 the Business and Rofessmns ode,and my license is in PANELS w
y� full foroa ens effect./
6 License Class fir/ Lic.N IJP T0200 AMPS - • •�, ♦♦♦
ti=y Dale Contractor 201-109RAMPS men
ZMvr� ARCHITECT'S DECLARATION OVER 1000 AMPS �QFT�OpRA FT.
C Z—O I understand my plans shall he used as public records. 11�\VVyE YY66..�e
SIGNSELECTRICAL �� T E R
Licensed Professional 16-(` 1
a Q
OWNER-BUILDERDECLARATIONthe CoATION SPECIAL CIRCUIT/MISC,
XOap., 1 hereby affrm(hut 1 am exempt from the Contractors License Law for the
�30J following reason.(Section'I03L5,Business end Professions Code:Any city
memory SISTER ETER OR POLE(NST.
rn which requires a permit to construct,alter,improve,demolish,or repair any structure DATE
'�,7,� priorlo its issuance,also eegmres the applicant forsuch Permit file a signed statement POWER DEVICES ` r
AO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter -
o�' 9(commencing with Section 7")of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION JIA
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of //���� 6.rir/
4 Smtion]03L56y any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES {,/I /b�
not more than illy
hundred dollars(E500). (,,// \r��
❑ I,esownerofNe n NEWRESIDENTIALELECfR S .FT.
#ropey,ormyemployed motoned for slei(sole compensation, Q STORIES TYPE CONSTRUCfION
a3— will dothe wons and the he Coreisnoria Liceese Law do snot apply 704,T,Business -
andpro Professions Cade:The improves
Contractor License Lew does not apply lf an owner of
properlywho
yces,pdsorimpmvesthimponand who dcensuch
tende Mmselfonhroulf.If
own employees,# ed not themre, OCC GROUP RES.UNITS
buwevecillhathe building the
buries of po mnt issal he diinot build oimproefor,turposef TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). '
❑ I,as ownerofthe properly,amexclusively contracting with licemsedccamost nsm QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct rhe project(Sec.9044,Business and Professions Code:)The Contractor's
License Law does not applym anownerofpropenywho builds orimproves thereon.end PERMIT ISSUANCE
who contracts forsuch projects with accountants)licensed pursuant to be Contractors
License Law. ALTER-DRAIN&VENT-WATER TEA) FEE SUMMARY
CII on,exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTRuNt FEES
SANITARY Y N_
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTM
c WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑ Thereby affirm that l have a cenificateofconsent toself-insu(goracertificate of FIXTURES-PER TRAP RECEIPT'#
Workers Compensation insurance or a certified copy Thereof(Sec.3800,Lab C.)which PARK FEE Y N
ars all under this permit. GAS-EA.SYSTEM-1 INC.S OUTLETS RECEIPT#
Policy n' BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy ie hereby Pomiehed. ' '
❑ Certified copy is fled with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Has section need not be completed How permit is become hundred dollars($100) SEWER'-SANITARY-STORM EA.20l ENERGY FEE
orless.)
I certify that in the performance of the work for which this permit is issued,l shall WATERHEATERW/VENTJELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation LawfgfLalifginia. to WATER SYSTEMITREATINO Date Receipt#
'Z APPlicant �//'Lilyd f/
0 NOTICE TOAPPLIC T:If,after making this Cerifiwte of Exemption,you should t NEWRESIDENTIALPLMIL SQ.FP. TOTAL:
AJ
become subjecuas the Worker's Compensation provisions of the Labor Code,you..at
�i ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a convection lending agency for the performance of
V O the work for which this permit is issued(Sec.3099,Co.C.) TOTAL: ELECTRIC FEE
LL Lenders Name - -
0 U Lamers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that I have read this application and state that the above information is
a correct.l agree to comply with all city and county ordinances and slam laws relating to PERMIT ISSUANCE MECHANICAL FEE
tibuilding construction,and hereby aumodrn representatives of this city to enter upon the
L) Z above-mentioned
property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cuperlino against
liabilities,judgments,costs and expenseswhich may many way accrue against said City AIR HANDLING UNIT TO 10,000 CFM)
in ocase, ""^"����e of the granting of tWI[ l
L// AIR HANDLING UNIT(OVER I0,000 CPM)
Signature of 1wasuContractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) - Dare Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I(EATING UNIT(OVER 100,000 BTU) TOTAL:
Code,SccdF)25532(e)P VENTILATION PAN(SINGLE RESID)
❑Yes ❑No -
BOILER-COMP(3HPOR i(q,000BTU) - ISSUANCE DATE
Will[heaconta irate,or as building by the
Alto Air ordevi Marmchemh P p a D
• Drardws air contaminants as defined by the Bay Aree Air Qoeliry Mamagemem BOILER-COMP(OVER 100,000 BTU) V' P1 4J
DiaricR NOV1
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,Pf. N + 2 1992
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 255U. 1 understand that
if[hebuilding does
quirem nts w have h must
et poor
r to issuance responsibility mortify rhe C1 (o Ur CTI({r'NC JaC 7
occupant of the requirements which mull be met prior to issuance of a Certificate of - Imo''/��/
Occupancy.
Owner or audiences]agent Date TOTAL: ISSUED BY:
OFFICE