24653 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBINGROJECTECHANIFIC 24653
^ 6 5 3
BUILDING PROJE(:'1'111ENTiFICAI'IfIN L� JJ
BUILDING ADDRESS s�� SANITARY NO. APPLICATIONSUBMITTALDATE
•
. Ov ^ Y # I7^� UNIT# .LOT# t/a�
OWNERS NAME: PHONE: c7,� / CO j�CTORIS AMC: 1 �1 1.1 NO:
rbr� J _ ' / JgJ i/ Gttn 41 ` I Iylln rv/c CON ROL#
RCHII'ECDENGINEER: LICNO: AD gEUS:0VA ^b (3b F-1CONTE:ACT: PHONE _ r/I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
UMB 'Ri
PERMIT ISSUANCE• BLDG FtK PLL�f(FN'
` � � s x//yl'
LICENSED CONTRACTOR'S DEC12AMI ION APPLIANCES-RESIDENTIALnmz JOB DESCRIPTION
VJOO Thereby Divihatl unlicensedinss itvrotesttions Codle,and
my license is
P^100 fullSection WKKdef Divisiov3 of Ne Business and Profesxioru Cak.enJ my licca.¢is in PANELS
eJG� full force and effect
g:Zu] Licens Flims C2f�' Lic.p UP T0200 AMPS �a
Consrno 201.1000 AMPS
z8O-K ARCHITECTS DECLARATION OVER I"AMPS SQ.FE FLUOR AREA J/S .FT.
O Z—a I understand my plans shall be used to public rccmds,
F SIGNS ELECTRICAL.
LicensN Professional
p.
OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
1'Q
XOiF 1 hereby affirm than 1 am exempt from the Contractors License Law for the
ts13Qm fnllowingreassm.(Section](I31.S,Business and Rofessiuns Code:Mycisy nr coumy TEMP.MEG3R )RPOL� WT1r�� 'N1
as
which requires a permit no construct, lou ,improve,demolish,or raped,any.anew.. s
!!1Y7 prior to its issuance,also requires the applicant forsuch Permit file a signed stmm
cent POWER DEVICES '
�y D O that he is licensed pursmm m the provisions of the Connrenors License Law(Chapter 1 J� t
a zz as is I
9(commencin )
with Section 700 of Division 3 of]he Busimeand Professitma Code SWIMMING POOL ELF IC VALUA]
y A t
^y or that he is exemptahcmfmm andthe basis for allegedexemplam.Any violation of \�
F Z 4 Section]031.5 by any applicant for a Permit subjects the applicant to a civil penalty of OUTLF!f5'-SWITCIior
t mothan five hundred dollar(5500).
W m nre❑ I,usowneroftheproperty,ormyemployenwithwagesulkirsolecompcn.1ion, NEW RIES113RIGO, ELF _ RC UCf10N
63t will do the work,undshe stmnure is not immoro
�dcdffered for sale(Sec.]o44,Business
and Professions Code:Tic Qmtracmrs License Law does not apply no an owner of DATE
property who builds.,improves thereon,and shodoessuch work himmlfanhrough his
empl.yces,provided Wntsuch improvemculame not innendcEmoffered formle.If, , "—GC'C.GROUP RES.UNITS
however,the building or improvement is sold withmone ycarofcompletion,nheowner- —�
builder,will have the burden of proving slim he did not build or impose for purpose of
sine.).
❑ I,as ownerofthe pr.puny,umexclusively connecting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7M4,Business and Professions Cale:)The Commcror's PERMIT ISSUANCE �•
License Law doe s.apply to ano ou,,dpropcny who builds or improvesthercon,and
who convects for such projects with a commcwr(s)licensed pursuant no the Contractors ALTER (fid)
License Law. FEE SUMMARY
❑ 1 nn exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE-
SANITARY Y N
Owner Date RECEIPT'#
DRAINS-FLOOR.JUDGE,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby effinn that I have a eeni6eme ie consent toof(S..381or o anificare of RECEIPT N
FIXTURES-PER TRAP.
Workers Compcwsionlmaranceoru<ertifiW copy.hereof(Sa.38fq,Lab C.7 which PARK FEE YN
wen all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS
Certified
SYSTEM-OVER 4(EA) PLANCHECK FEE?
❑ Certifmdc yishercbyfumishl
Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FF.R
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
I (This.tion need not be completed iflhe permit is bnone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify than in the performance of the work for which this permit is issued,l shall WATER HEATER W/YENT/ELECIR
nos employ any person in any..in so.or become subject to the WorkersPAID
s ,z Compensation Lawsof Califomin. Dam WATER SYSTEM/IREATING Date Recciptp
Applicant
2 C) NOTICF TO APPLICANT:If,after making this Cedificnte of Exemption,you should NEW RESIDENTIAL PI SQ.ff. TOTAL:
U). become subject to the Worker's Compensation Provisions of the Labor Cale.you must
a forthwith comply with such provisions or permit shall be deemed revnkel. BUILDING FEE
W z I CONSTRUCTION LENDING AGENCY SEISMIC PEE
Ell I hereby affirm that there is a construction lending agency for the performunceof
V O the work for which this Permit is issued(See 3097,Civ.C.) O ELECTRIC FEE �r
Lender's Name PLUMBING FEF.
O F Lendcr'a Address QTY. MECHANICAL PERMIT FEE
V 1 certify that 1 have read this application and state that the above information is
4 e.mecs:I agree to comply with all city and county ordinances and state laws relining I. PERMIT ISSUANCE MECHANICALFEE
E^ U) building construction,and hereby authorire representatives ofthis city to enter upon the CONSTRUCTION TAX
V Z ubsc-mmio
ened progeny for inspection pu poses. ALTER OR ADD TO MECH.
(We)agree no save,indemnify and keep harmless she City of Cupertino against
fiabillti ,judgartax.cmirsandexpewswhich may in any way aseuragainat sad City AIR HANDLING UNIT(TO 10,0(10 CFM)
iricia uencc of the gmnrin f is'mah. AIR HANDLING UNIT(OVER 10,"CFM)
utureof Applicam/Contomor Doe EXHAUST HOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dune Receipt#
Will the applicant or more building occupant sore or handle hvurdous material HEATING UNIT(OVER 100,000 BTU) TOTAL'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Healdn and Safety
Cade,Session 25532(n)'!
❑Y. 11 No VENTILATION FAN(SINGLE RESID) —e
Will she¢ licmm�rfuwmbuildin taste tai BOILER-CONIC IMP OR 101.0110 BTU) ISSUANCE DAT
hPaseadpp goccupan q pmenmrdevicn whichemit �
oro air contaminants as defined by she Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
I-is
'strict?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have road the havnrdaus materials requirements under Chapter 6.95 of the JAAf -41993
California Health&Safety Code,Secdons 25305,25533 and 25534.I understand thus (� -
if dre building does not currently have a mount,that is is my responsibility to notify the `j'I Y Uraccupms of the rcquiremcnls which must be met prior to issuance of a Ci nifi,me of I'UrCfx I
Occupancy. VP ,
Owner tar authoriudagem Dam T � ISSUED BYI VWIZWJ � �w
OFFICE