24540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- LECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. A /1 c 0
BUILDING PROJECT IDEN'L5
'IFICAI'ION L 4
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
s UNII•N LOIN
PHONE: CIlglTRA OR'S NAME: Ir{NV�--�r`
rC 1/7e�- N/C CONTROLN
• A CHITEC!/ENGINBER: LIC NO: A DRESS: 7 ❑
CONTACT: PHONE:
/JJ1yss/ (�c/(� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
aIs, / ax f!c 0 / • PERMIT ISSUANCE BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑
APPLIANCES-RESIDENTIAL
11"
a'Z Ihcmby on that l 3 ofth Businasiand Profession,
Code,
my ficeme with JOB DESCRIPTION
ts100 Section]000)of Division 3o(Ihe Busincu trod Professions Code,and mylicemeis in pA�� � �/�
�Fj U full(orw nnJ effFy .s� _
"Z Licrnse ClasJr_`jJp_Lic.p I.5 UPT0200AMPS
yF-=yComrazmrs r P 201-IOOOAMPS
ZOy^ 7 A HITECTS DECIA TION JJ/J�'� SQ.FT.FLOORAREA
pZ^G Iundenland my plane shell be used us public records. yT/yr' OVER I(IUOAMPS ETSQ.FT.
1•'•j2"J SIGNS ELECTRICAL
yyqg ¢ lacensed Profeastonvl OWNP.R-BUIIAER DECLARATION SPECIAL CIRCUIT'/MISC.
X O a.V 1 hereby afNw that 1 nm exempt from the Conrmcmr's Liwrme Isw fm the
w'Dy following rtasoa(Sanion 7071.3,Buxinas and Profession Code:Mycity ar count' TEMP.METER OR POLE INST.
rn 5 which requires a pewino consrmcr,eller,improve,demolish,or repair any swmurc
!!(a� prionoitn issuance,ulxn requires the applicum for such pewit to file aligned smtemcnl POWEN DEVICES
yy p That(rearmament,
pursuanttothe pro hvishof the Convacros,License a i (Cheerer
of
f Met hemixempt creiner,adon the
3o(the Business end.A(bssiom Cod e) SWIMMING POOL ELECTRIC VALUATION
mthat 7031. by
refromnt f the permit subjects
alleged applicant
to civiny l
of
CGnet
Section7031.5v aundredicantfmapermit subjenx the epplicwno acivil penally of OUTLETS-SWITCHES-PIXTURES
not mom than five hundred dollen(5500).
❑ 1,asownera(Neproperty.armyemployceswithwegesazlheirsolecam anon, NEW RESIDENTIAL EL CTR
y will do the wnrk,anJ theswcmrcienot inrcndedaroffered for sale(Sec.7(W4,Business RIES TYPECONSTRUCDON
and Professions Code:The Comractor's License Law does not apply to an owner of I tI
pmpenywhobuildsorimpmvothereon&ndwhod ssuchwodhimselfmrlwughhis g
h wemployees,pmvidedlhatcuchimpmvcmernsamnmintendedoroffcr forsale.if / OCC GROU RES.UNITS
ever,the buildingerimprovemem issold within one yemofcnmpldion,the owner-
builder will have Ne burden of proving that he did not build or improve for purpose of AL'
sola).
❑ I,axnwner ofthe property,amexdmiv<Iyconlmcling with licensed enntredorem QTY. PLUMBIN4PERMIT FEE FLOOD 20NE APN
'onpmct the project(SIN.7044,Business and Professions Code:)The Contractor'&
Licenx Low does and apply roan ownerafturpeny whobuildsorimprovesmareon,and PERMIT ISSUANCE �'
whocenwets forauch projects with awnrsacmr(s)licensed pursu=t tothe Conwctoes
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
ClTam exempt under See. ,B&P C far this reason O I E FE
BACK FLOW PROTECT.DEVICE
Owner SANITARY Y
WORKMAN COMPENSATION DECLARATION N
•
Date DRAINS-FLOOR,ROOP,AREA,CONU. RF;CEIPTN
_N
hIherthy vffirmthetlhaveacmi0wm of conscnno mlf-insure,ore wnifiwre of SCHOOL.TAX Y
FlXTURES- RECL•IPI'N
ars'Compensetionlnsurnnce oracendied copy lhereef(Sce.380,4b C.)which PER TRAP PARK FEE Y N_
covarsall plo e' un&M =i1. GAS-EA.SYSTE .4M-1 INCOUTLETS RF.CEIPf p
1'nlicyp_ wlTpw�
Compact) �jTr Z DUILDING DIVISION FEES
❑ CentBN. yM1�gAfb)7(Q�sb GAS-LA.SYSTEM-0VER4(Eq) pLgNCHECK FEE
'4 MHcd copy is filed wirhthe city inspection division. GRFASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOUS TLE
COMPENSATION INSURANCE
(This section need not be completed Hine permit is forces hundred dollare(SI0(j)
or less.) SEWER-SANITARY-STONM EA.2(gIT. ENERGY FEE
I certify Nat in Ne Perfowenceofthe work fm which Nis pewit is issued,Isbell WATER HEATER W/VENIVELECTR
oI employ any person in any manner se as to become subject m the Watters' PAID
Z Compensminn laws of CalEnron,. are WATER SYSTEM/IREATING Date ReceiptN
O O Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB.
rA become subject to the Worker's Compensation Previsions ofthe Labor Code,you muss TOTAL:
forthwith comply with such provisions or his pewit shall be deemed revoked. BUILDING FEE
CilQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
7-. I hereby affirm that them is a construction lending agency for performance of
U O Ne work for which Nisawit is issued(Ser.309],Civ.C.) TOTAL: aS ELECTRIC FEE
Lendera Name
U.
U Undoea Address QTY. MECHANICAL PERMIT FEF. - PLUMBING FEE
Ila 1 certify that I hav<rcad this application and pate that the above information is
correctl agree to comply withal]city and county ordinances and pare laws relating to PERMIT ISSUANCE MECHANICAL FEE
V) buildingmnswction•and hereby au@odzertpmaematives of Nie city Income upon Me
U ,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 Cupertino against
liabiliries,judgmenes.emesand expenses which may in eeyway Mende .lost said City AIR HANDLING UNIT ITO 1,000 CFM)
m saquenttof rhe gmmi ! is pewit.
10 CA 0,- `� AIR HANDLING UNIT(OVER 10,0pI CFM)
Lure dApplmswconrracmr Y Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOO,OW BTU) Dam al
Will Nc epplicanl or future building mcupant Blom m handle hazardous material
az dented by rhe Cupenine Municipal Cade,Chapter 9.12,and Ne Health sad Sa(ny HEATING UNIT(OVER IO,t10p BTU)
Code.Section 25532(a)7 6
11 Yet ❑No VENTILATION PAN(SINGLE RPSID)
Will Nee licaumfunum bui]din encu ant use BOILER-COMP OR IOO,pq BTU) ISSUANCE DATE
e 8 P equipmentouality Management Y- A i D
hazardous air comnminums as deNned by rM1e Bey Arca Air Quality Management BOILER-COMP(OVER 1011,000 BTU)
District!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have mad the hazardous materials requirements under Chapter 6.95 of the DEC 10 1992
Ca ifomia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand Non
if ccupanilof the res not mentacurrentlywhich
m st be teal it is my responsibilityuacof
to thea the CITY OF CU�CT a Ia
occupant of the requirements which must be mer prior m issuance o(e CeniFicam of
Occupancy.
Owner or vuNonzN agent Data
TOTAL: ISSUED BY:
OFFICE