24927APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE ay
CITY OF CUPERTINO BUIL N'G-RLECTRICAL
BY OF C § N APPLICATION/PERMIT PLUMB NG
BUILDING PROJECT IDENTIF'ICAT'ION
PERMITNO.
24927
BUILDING, ADDER
SANITARY NO.
APPLI}}CaaA��TION SUBMITTAL DATE
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1
20t�J K 1UNIT# LOTH
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❑
CONTROLp
RCHITECT/ENGINEER: LIC NO:
�Rys$: t CA �� 7,
• s IRIVnIx
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ECT PLUMB MECH
❑ ❑ ❑
PERMIT ISSUANCE J
p pc Z.
:+100
Y a�1
QZ
LICENSED CONTRACTORS DECLARATION
Ih7")offrmthat l sum mmrnense with
rofesioCCode,
APPLIANCES -RESIDENTIAL
_ JOB DESCRIPTION
,r'71.^�w'a//�.7, N
Section 71X10) of Division 3 of the Business and Professions Code, and my license is in
Business and and
full force and cffceh' O b5"15 / \
License Class Liu.# -
PANELS .
Up TG 200AMPS
n y
jNZ—
y..0
Date Contractor
101 - 11100 AMPS
ARCHITELTS DECLARATION
I understand my plans shall be used as public recnNn.
OVER lap AMPS
�5Q0FLO R !
$/SQ. FT.
SIGNS ELECTRICAL
3
yv GLicensed
Oy V
13i, wON
y;
C Op
I�
y!
o v
professionalIre.
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Lew for the
Noe n"mo n. (Section 7031.5, Business and Professions Code: Any city or county
which requires o permit M construct, allm. improve, demolish, ar reMir any strucmm
prior to issuance, also requires the applicant farsuch permit o file u signed.turrot
that he is licensed personal a the provisions of the Contractors License Law (Chapter
9(commencing with Section 7") of Division 3 ofthe Business and professions Cale)
SPECIAL CIRCUIT/MISC.
TEMP. MI3MR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
—,�
4
K G
W w
nr Nal he is exempt and the basis for the alleged exemption. Anyvialatim.
Section 7031.5 by any applicant for o permit subjects the applicant a. civil perchy of
not more than five hundred dollars (§5007.
❑
wrk,andepropeny, OrmyempinyeeawiNwegcsmthei(Sao7044.Bsiiess
pVALUATION
��� psi
OUTLET'S - SWITCHES - FIXTURES
NEW RFSIDIIIAL ELECTR _SQ, FT.
STORIES
TVPE CONSTRUCTION
L
will danhewonx and the no
othe Business
(Sly
aletimenense
and Professions Calc: Cmerracture
Contractors License Law does not apply to res owner of
Lawnet I.an
me
pmpenywyees, pdsorimprovsuch toproveromadcessuuhwmk himsdfanhroughhis
cow imp msurene intendedmplferedfbes
OCC, GROUP
RFS. UMTS
aver,tyees,p ing oxithatsuch
is sold
however, the building oximprovement is sold within one yam of canplttion. the owntt-
mar,
builder, will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sole.).
❑ I, m ownerofthe Property, amexclusively contracting with licensed contractors o
FLOOD ZONE
APN
construct to propel (Sm. 7044, Business and Professions Cma:)'Uto Contractors
License Lowd«snot apply toanownerofpropeny whobuilds th
crimp r vescrecm,and
PERMIT ISSUANCE
who contracts for such projects with acanbmands) licensed pumumtto the Comuaumrs
License law.
ALTER - DRAIN&VENT - WATER (PA)
FEE SUMMARY
❑ I nw exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
O UTY DE FEES
SANITARY N
Owner Date
10 WORKMAN COMPENSATION DECLARATION
y Ihe¢byaffirm that l have a certificate ofmasem to se10imum, or a conductor, of
WorkenXCompensation Insurance or a certified copy thereof (So, 3800, Lab C.) which
pRAINS-FLOORROOFAREACOND
, , , .
RECEIPT
SCHOOLTAX Y N
RECEIPT#
FIXTURES -PER TRAP
PARK FEE Y N
covers I e's 4n yyyy.m t.
PoliryN �1�QP�$5� 1 7i-1L�_�Z
RECEIPTp
CAS -EA. SYSTEM. INC.40UTLEfS
BUILDING DIVISION FEES
Company k"s[LFU;(UP%M�'
GAS - EA. SYSTEM -OVER
PLANCtIECK PLE
❑ Certified mpy is hereby fumimed.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING HE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPHON FROM WORKERS'
GREASETRAP
SOILS HE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be completed tithe permit is format hundred dollem($100)
a,less.)
WATER HEATER W/VENT/ELECRt
I certify the in the perfammnce of the work for which this permit is issued, I.hall
not employ any person in any manner so as to become subject to the Workers'
PAID
,z
v
7 U)
Compensation Lawtof Califomia. Date
Applicant
NOTICE TO APPLICANT:IL.ftm making this Certificate of Exemption, you should
became subject to the Workers Compensation provisions of the Labor Code, you must
TE
WATER SYSM/fREA'TING
NEW RESIDENTIAL PLMB. SQ. FT.
Date Remcipt0
TOTAL:
forthwith comply with such provisions or this permit shall be deemed evoked.
BUILDING FEE
SEISMIC FEE
Q
CONSTRUCTION LENDING AGENCY
J z
O
I hereby affirm that hem is a construction lending agency for the performance of
the work fm which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Leaders Adders
• Ha
9t.correct.
Ca)
Z
I verify that 1 have read this application and state that the above information is
lagree mcomply with all city and county ordinances and state laws relating m
building construction, and hereby authentic representatives ofthis city menter upon the
above-mentioned pro inspection proposes.
PERMIT ISSUANCE
MECHANICAL FEF.
ALTERORADDTOMECH.
CONSTRUCTION TAX
(We) a t madly end keep harmless the City of Cupertino against
n
limb' nt.,ce andexperseswhichm al;ay armacagainstsaid City
AIR HANDLING UNIT (TO 10,(100 CITE)
of g this it.
_
AIR HANDLING UNIT (OVER 10,000 CFM)
ignmu fAppIkuvVCmntmamf Date
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building am,am sate ar handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and Be health and Safety
BEATING UNIT (OVER 100,(X10 BID)
Ta
TA
Code, Section 25532(td?
El Yes ❑ No
VENTILATION RAN (SINGLE RESTD)
BOILER - COMP (3HP OR 100,1100 BTU)
ISSUANCE
Will theepplicanwr future buildingaccupanmueyuipmenmrdevicerwhich emit
BOILER - COMP(OVER 100,000 BTU)
heamdaus air contaminants as defined by the Bay Ars Air Quality Management
District?
NEW RESIDENTIALMECH. SQ,Ff.
❑ Ya ❑ No
I have read the hasardous materials acquirements under Chapter 6.95 of the
q
PAID
9
Califamia Health & SafetyCade, Smtions 25505, 25533 and 25534. 1 understand Nat
comprf the uilofflue esno, curently ant, that it is my responsibility to notifythe
^
whhmust
occupant of Ne requirctrtcnu which mux h met prior to issuance of a Certificate of
"/H
NA 3o
Occupancy.
'
ISSUED BY:
Owner or authoriood agent Data
TOTAL:
OFFICE ay