24558 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x H.DI G-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
24558
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRI?SS: I SANITARY NO. AP/PLLIICA'DONSUBMRTAAL
ro5 LDATIi
D2I Vf UNITa LOT# 1 L—� q
O �F.RS NAME: E: CO CIOR'S NAME: LIC NO: V•s
G a PIfON4 zt -A` � 0� NIC CONTROL#
•ARCHITECf/ENGINEER: LIC NO: ADDRESS: ❑
ssrCONTACT: µ PHtJtN'E: tJ eL S Sh*j .loy�
QTY, ELECTRIC PERMIT FEE `•, BUILDING PERMIT INFO
•, - _ LDO E P uVl Qi
PERMIT ISSUANCE f �I/yQF
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _ TOB DESCRIPTION
mwz I hertbyuffirm that l amlicenaedum]erprovistonsof C'Mpter9(mmmencing with
t 00 Section]000)of Division 3 ofthe Business and Professions Cade.and my license is in PANELS Pow-ars'
F2 I.tceme"C�6 full force l
e14_3rS_S_Carl � JI 201;4UPT0DAMPS r
may Dam TCTSIor_ ST 201. tX10AMP5 SQ.FT.FLOOR AREA S/SQ.Fr.
ZFNZ� ARCHITECTS DECLARA ON OV RI P
OOOZ^O lunders ypl�ns shat h upubl/t'c�recoNs
Q�� rel rd�.ka d i SIG F. t ]CAL A L E R I N
66'' a Uttnse
OWNER-BUILD from
m the Con TION CIALCIRCUIT/ % p U T E R
OyU I hereby affirm Oto 1 um exempt from the Conwcmrs License Lew for Nm
!alit+-rFir following reason.(SWion]0315,Business and Professions Cale:Any city or county TEMP.METER OR LE .T.
el
which rcquirca a email to construat,aluer,improve,drumbl..or topa]r any su mre POWER DEVICIiS
prima,its issuance,also requires the applicant for such permit file a sipolsmement A�
W ADOm Not he is licensed pursuant o the provisions ofthe Contractor's License Law(Cbapmr $WIMMINGPOOL ELECTRIC
�'�eLL 9(commencing with Section]000)of Division3of Ne Business and Professions Code) VALUATION
WF.=vA ardor he is exempuherefman and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FTXTORFS O 4V
❑�Q
Section 7031.5 by any applicant for a permit subjects the applicantto a civil penaltyof Q
t not more than five hundred dollars(6500).
lrtG NEW RESIDENTIALELECfR —SQ.FT.
I � ❑ I,asowncrnOheproperty,ormyemployaswiMwegesmtheirsolecompemadan. STORMS TYPE CONSTRUCTION
a willdotlic work,andthestmmure is not intended oroffcmd forsale(Sec.7W,Business
and Professions Code:The Cort ctols License Law does not apply mon owner of
property who but Ids or improves Neuron.and who does such work bi mself or through his
ownemployees,provided that such improvements went intendedorofferedforsa]e.If, OCC.GROUP RES.UNITS
however,the buddingorimprovement is sold within one year ofcompletion,the owner-
builder will have the harden of proving that be did at build m improve for purple of
aalcJ. QTY. PLUMBING PERMIT PEE ILooD ZONE APN
❑ I,us owneroflhe progeny,umexclusivelyconwmingwiN licensedcontraztorsm
construct the pmje a(See.7044,Business and Profewdons Cotler)The Contractor's PERMIT ISSUANCE.
Li cense law does om apply m an ownetnf properly who builds or improves tMreon,and
ez
whocontnmsforowlt projects with acomrunor(e)licearedpursuant m the Contractor's se Law.
License
ALTER-DRAIN&VENT-WATTiR(EA) FEE SUMMARY
❑ l am exempt under Sec. ,B&P C for this reason Vffgr
BACK FLOW PROTECT,DEVICE O IDE
SANITARY Y N
Owner Data DRAINS-FLOORROOF,AREA,COND. RECEIPT#
,
WORKMAN COMPENSATION DECLARATION , . SCHOOL TAX Y N
• ❑ I hereby affirm that l have a mitificale ofcomant to self-insure.or a certificate ofRECEIPTp
FIXTURES-PER TRAP
Workers11 mr&nmtionor,this por a ermit,
iged copy Hereof(Sea 3800,Lab C.)which PARK FEE Y N
RECEIPT p
coven all<mploye<'s unJer,this permit.♦•r�� 11 s1, ' f aces GAS-EA.SYSTF.M-I INC.40UTf.GfS BUILDING DIVISION FEES
PmlicyN �I� 7i i
[J Card l C GAS-EA.SYSTEM-OVER4(CA) PT.ANCFIECK FEE
❑ Certified copy is hereby with
fire cd.
Certified copy is fled with the city inspection division. GREASI?nNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SONS FEE
COMPENSATION INSURANCE
(This secomtrued nm beutmpleted if Neperm,is foronehuodred do11an(f100) SEWER-SANITARY-STORM FA.200F7. ENERGY FEE
or less.)
I certify that in the performance of the work fm which this pertnit is issued,l shall WATER IffiATF.R W/VENTIELECIR
not employ any person in any manner so as to become subject t0 the Workers' PAID
zO
z Compensationlawsof Califnina. Date WATER SYSTEM/TREATING Date Recript#
Applicant
O NOTICE TO APPLICANT:If.diet making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
t-I (q become subject to the Workers Compensation provisions of the Labor Code,you must a.r�
forthwith comply with such provision or this permit shall be deemed revoked. BUILDING HE
SEISMICFEE
(� CONSTRUCTION LENDING AGENCY
O
I hereby affirm that there is a comtrunion lending agency for rhe performance of
U ew ��
the work for which this permit is issue)(S 309],Civ.CJ e24L: ELECTRIC FEE
(Y Lender's Name
Q Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify Nat I have read this application and state that the above information is lb MECHANICAL FEE
correct.lagmr to comply with all city surd!county endurances and state laws relating to PERMIT ISSUANCE
building construction,and hereby salmon mpresenmtives oflhis city menter upon the CONSTRUCTION TAX
V above-mentioned property for impaction purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify and keep harmless the City of Cupertino against
liabtltttesjudgm b,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence he granting of this per
/�/�L AIRHANDUNG UNIT(OVER 10,WCFM)
Signature of App ca tIm Dem EXIIAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HCATINGUMT(TO IW,000 BTU) aa•"t. Dam etti
Will maii,plicam or future buildingnccupant entrew handle havrdom material HEATING UNIT(OVER Ryt BTU) AL:
as deftnal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)Y VENTILATION FAN(SINGLE RPSTD)
11 Yea 13 No PI&INCP.DAT.
Will theappltcantmfmure buildingoccupantmeequfpmentmdeviees whimemit BOILER-COMP(3HP OR IOQIXIO BTU)
• ha ardso s is conumimous as defined by the Bay A.Air Quality Management BOILER-COMP(OVER Fitt BTU)
District? DEC 7 1992
❑Yes ❑No NEW RESIDENTIAL MF.CII. SQ.FT.
1 have read the haemdom matadals requtremems under Chapter 6.95 of the CII 1 lJl" IaUF'Cfl 111VW
Califomia Hulth&SafetyCoda Smlions 21505,25533 and 25534. I understand Nat
if the building does not currently have a tenant,that it is my fexpns]bi]ity to notify the
natural of Ne requirements which must be met prior to issuance of a Certificate of �s.� '
Ocrupncy. ` 1 (� R
Ownermnarair.edugent Damsss' ISSUED BY: V �J
OFFICE