24629 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B R.DI .-EI. c RI AI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM RojEcTEDENTICAL 24629
BUILDING PROJEL'I'113EN'fINICA'I'IUN
BUILDING ADDRESS: �• SANITARY NO. APPLICATION SUBMITTAL DATE
O { v UNIT# LOT# I Z 1���
OW SNA E: P CO RACfOR'S NAME .IC NO: l{l
NIC CONTROL#
ACHIMC17ENGINEs : LIC NO: A FSS: d ❑
ONTACf: PHONE:
•' QTY. ELECTRIC PERMIT FEE- BUILDING PERMIT INFO
{.�s/G� BLDG .LF. UM ME
PERMIT ISSUANCE
LICENSED CONTRACTOR'SDECVam,sr,N APPLIANCES-RESIDENTIAL LOB DESC ON
O C'Z Ihercby al titre tnU emliansed unJerprovisitnanf Chapmr9(cI my beenso sed
�00 Section 7")of Division 3 of the Business and Pmfouaux Cade,and my license is in PANELS
o� once and eIT .f
FZ, uCLic.p �A4�f�y� UP.TO 2(p AMPS ACD 0
rn< Date Comndor 201-10(10 AMPS
OZN ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.FLOOR AREA s/SQ.FT.
I undcrstan y plans shall be used as public records. �� 1�
y SIGNS ELECTRICAL
K Licensed Professional
ti�n1UOWNER-BUILDE.RDECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that 1.m exempt from the Contracmrs License Law far the
pts 3 n.y following am .(Scotto 7031.5,Business and Professions Code:Any city.,county TEMP.METER OR POLE NST.
E10y sowhich requires a permit to construct,alter,improve,demolish,or repair any structure�� prianoits issuance,also requires the oppliaantforsuch pemduo fileasignm smmmem POWER DEVICES
Gthat he is lica aed pursuant in the provisions of the Contractors License law(Chapter
e 9(commenting SWIMMING PODLELECIRIC
( gwith Sectian]q)B)of Division the Business and ProRssims Cale) VALUATION
_y or that he is exempt therefrom and the basis for the alleged exemption. w
Anyviolmonpf �1
E•zQ Section 7031.5 by any applicant for a Permit subjects the applicant ma civil pvmltdof - Lis ` �
0 nr more than five hundred dollen(5500). ,I J
en ❑ 1.as.wneroftbepropcny,ormyemployeeswilhwagesastbeirsolecompensutioo, R ID sect. 1 STORIE TYPE CONSTRUCTION
willdothe work,and theanuctre isnot mm iledmoffcred fo...to(Set.7044,Business
and Profess ns Code:The Commcter's License Law docs not apply to an owner of Il
pmpenywyers,pdvidedtrovesthimpgandwht=notna work himteredh ambo is OCC GROUP RFS.UNITS
.wnemploycea,providmthet such improvements=not inrcnded.roffrrcdforsale.If, _
howeverthe building or improvement is sold within one year of completion,the ow r
builder will have the human of proving that he did not build or improve for nations
wle.).
_ ❑ I.asownerofthepmpcny.amexclusivelycmn mingwimliemn cmctmio QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmjm(Sm.7044,Business and Professions Code)The Commcmr'e PERMIT ISSUANCE
Wsenna LawdoesnotapplytoanownerofproperrywhomiIdsm mpmves thereon and
who contracts for such projects wit a connectors)licensed pursuannmhe Contractor's EA-
ALTERDRAINffiVENT-WATL•R �•
Lice...Lou. ( ) FEE SUMMARY
❑ 1 em sumps under Sec. B&P C for tNs reason BACK FLOW PROTECT.DEVICE Offffffll FEE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX Y N
❑ Ihercby afOrtn tatlhave ncenificam of consenuo selGinmrc,om cmifimm of FIXTURES-PER TRAP f RECEIPT#
mkm Compensation lnsurancearacenified copy Nercof(Sec.3900,Lab C.)which PARK FEE Y N
covenas
all employee's under this permit. GAS-EA.SYSTEM-1 INC.4OUTLETS NECEIPf p
Policy p
�' BUIIAI DIVISION FRES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
ified copy is hereby furnished. fnim
Ceni6ed copy is film wit to city inspection division. GREASERNDUSTRL WASTE IM'ERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS
' COMPENSATION INSURANCE
(This section nem not he completed ifthe permit is for one hundred dollars(s100) SEWER-SANITARY-STORM P.200p. ENE Y • ' —#
no less.)
I certify tat in the performance of to work for which this Permit is issued,I shall WATER HEATER W/VENT/F.LECIR
not employ any person in any manner so as to become subject to the Workers' PAID
Compemationlawsof CaliPomia, Dote WATER SYSTEM/IRLATING Dane e
Q z-+ Applicant
z 2 NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMEL SQ.FT, t TOTAL:
t+ U) became impact 1.the Workera Compensation provisiom.fte labor Code,you must
� > forthwith comply with such provisions in this permit shall be deemed revoked. BUILDINGFEE
if
Lk1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE ev
1 hereby affirm tharthem is a construction lending agency fm to performance of
JO the work for which this Permit is issued(Sec.3097,Civ.C.) U ELECTRIC
Lenders Name PLUMBINGXE
r�
F Lenders Address QTY. MECHANICAL PERMIT FEE
V I certify that I have feel this applic.inn and stem that to above information is MEC I FEE
correct.l agree to comply with all city and county ordinances and sure laws mistingm PERMIT ISSUANCE /
building construction,and hereby amhmize repreuntativesofthis city to enter upon the CSTR ION TA
L) z .hove-mcml.nmprom
py far inspectionEB
purposes. ALTORADDTOMECH. !
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
hitintum,,jidgmems,cost. nd expenses which may in any way accede against said City AIR HANDLING UNIT(TO to."CFM)
is cm guns of the m;;1f tis Form AIR HANDLING UNIT(OVER 10,00)CFM)
Si fApplicam Cmi or Date EXHAUSTHOOD(W/DUCT) PAID
• HAZARDOUS MATERIALS DISCLOSURE
IfFATING UNIT(TO 100,0(0 BTU) Data Receipt#
Vr I the splicer,or future building occupant store or handle harardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532(0? VENTILATION PAN(SINGLE NPSID)
11 yes 11No
ISSUAN E DATE
Will the applicant or futmbuildingoccupmmmequipmem ordevices whiehemit BOILER-COMP(3HPOR 100,0110 BTU) p
random air conuminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER I(M."BTU) Y•
Distinct?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. MAR 25
1 have mad the hazardous materials requirements under Chapmr 6.95 of the �rI
California Health At Safety Code,Sections 25505,25533 and 25534.1 understand that Vr
iftbe building does not currently have a mount.tan it is myrespumibility to truly the L•V t
oecupant of to rcquircments which must be met Arrant issuance of a Cenificam of 1
Occupancy.
L
Owner ,or authorized agate Data � 17'�KpFqp ISSUED .
OFFICE