24681APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO tl II. Ih - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
A C O rI
/� G 4 U o 1
BUI 1GA50 1COI. �� /�nA CA ^S -O /
Vl J UNIITX / 7 LOT#
SANITARY NO.
APPLIGTION SUBMOTAL DATE
OWNC0.S AMG: PHONE'
ANbALv 26 R•ti1A7AkpJAA 3608
CONTRACTOR'S NAME: LIC NO:
Tophi
N/C
CONTROL#
�Q
RCHITECI'/ENGINEER: _ LIC NO:
- !N� ASSAY
ADDRESS:
21 19�` SfYeti 5'r�+'
r
CONTACT: PHONE:
p
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT L B E I
PERMIT ISSUANCE.
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WOO
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LICENSED CONTRACTOR'S ionsof RATION
Iherehy option that laEDlicensed underprovisianCof RAprer9 (commcncingwiN
Section 7") ofDivision] of fie Business and Professions Code, and my license is in
full force and effect.
License Class Limp
Duro Conn..r
APPLIANCES - RESIDENTIAL
� PANELS
UPT0200AMPS
JP S N
201-IOIKIAMPS
ARCHITECTS DECLARATION
1 a my plana shall 4 vxd as public records.
OVER 1000 AMPS
SQ. FT. FLOOR ARCA
$/SQ.IT.
SIGNS ELECTRICAL
seProle
licend Professisi onal
%Lf
400
<J
RYA
ZOO
Ce
u❑m
Y
OWNER -BUILDER DECLARATION
that 1 am exempt Iron the Contractors e: Any law for the
1 heathy reason. ction m,lo7031.5,BYne,, munition, derionsCNe:Any city or coumy
which followingrerca. Fa
which requiresnpermit loconNaehalmaimprove,demolish, me.sigudswcturc
that he sficarbcstaunce,alsorcyutdo Ne apmars aide opennons Glease La statement
9(comisncinsdpmrsuwue")ofDivisiof she Contractors and Prol..im.Cde)
or that veil emmiith Section 70001of Division th.ofthe ml,BusinessaN Professions Code)
efonhects theduemption. Any violation of
or that leis 1.5 by any
aN Ne baspermit
Section ]031.5 by any applicant fore parlors subjects the epplicennoncivilpmelty of
SPECIAL CIRCUIT/MISC.
'
,
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
w
UT-ETS- SWITCHES - FIXTURES ��
E
e�aadP�ficmiorc,
not than Gve hundred dollars (S50o).
sowneroftheprop M,nrmyemployeawithwagesastMirsolecomp adon,
(_TYPE
NEWRESIDENTIALELECTR _SQ.PI'.
TORTE
CONSTRUCTION
L3o0
ework,.rd thusnucome isnot imm�dedmmffen:d for snI (Sec. 7006, Busine
Code: The Comruco's License Law does not apply m ua uwncr
whobuiltiserimprovesthereon, and whodmssuch workhimselforthrough
,
wnemployees,pingor
impmvememsart nm eatro
OCCGROUP
RES. UNITS
omoffercd thams.
improvementtheow^--
huilder willhar. the v l the
rimpmprovin issoldhewithiniot build or, improve
huilder will have the burden of proving that he did not build or improve far p--''
burden
1 � O
le.).
❑ I,asowaerofthepmpeny.umexclusivelyconuaningwiNlittnsedconh.-
MBING ER FEE
FLOODZON9
ARK
construct the project (Sec. 7096, Business and Preeminent CNet) The Contractors
LlcenseLnw does not applymanowncrofpropeny who huilds orimprovu '.lawn,and
whocommcis forsuch projects with a conammom licensed pursuant o the Counselor's
Licavx Law.
PPILM ¢aNC9
---CR K—CR(EA)
r f'
FEE SUMMARY
EDI am exempt under Sec. B & P C for this reasonOUTSIDE
Y`
••y,r "•._ 1
_.
FEF_
SANITARY YN
Owner Data
`
DRAIN RFA, GOND.
�^
Iy%TIJRGS =pe.,^ ��
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Thereby allots that lhaveacemifceteofcons<nnoselGissim,oracerifrcamof
Workers'Compensation Insurancemorerdified wpyshercof(Sol. 3800, Lab C.) which
SCHOOLTAX Y N
RF.CF.IPT#
PARK tF.E Y N
cnven all employees under this permit.
Policyp
', /
GAS -EA. SYST:` r Q'� fa-
EC ra
BUILDI 1 ION FEES
Company
GAS - FA. SYSTEM -OVER
• <
PLANCHECK FF.[
[D Certified copy is hereby fumlehd.
GREASHANDUSTRL WASTE INTER 'OR
❑ Cenified copy is filed with the city inspection division.
GRADING FE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS
SEWER SANITARY - STORM EA. 200R.
Eb1MGY FEE
This section need not be completed lithe permit is foronehundred dollars 5100)
orlessJ
WATER HEATER W/VENT/ELECTR
I cenify that in she perfornsnce of the work for which this permit is issued. I"I
wt employ any person in any manner so as to berome subject to the Workers'
PAID
Z
Compensation Lawsof Califomia. Data
Applicant
WATER SYSTEM/TREATING
Date Receiptp
0
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
M
become subject o the Worker's Compensation provisions ofthe Labor Come, you muss
forthwith comply with.mch provisions or this permit shallh deemed revoked.
BUILDING FEE
SEISMIC FEE
O
(]
CONSTRUCTION LENDING AGENCY
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O
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U
0.
y
Z
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
ELECTRIC M133,tea
Lenders Name
1masts Address
I ramify that I have read this application and state that the above information is
comes'. l agree to comply with all city and county ordinances and state laws reining m
ae mprtsenmtives of Nis city to eer upon the
building conswctirur unit hercbyaushodat
above-mentioned property for inspection purposes.
QTY. MECHANICAL PERMIT FEE
PLUMBING FEB
MECHANICAL FEE
PERMIT ISSUANCE? /s
ER
ALTOR ADD TO MECR. �^
CONSTRUCTION TAX
(We) ng. m save, indemnify and keep harmless the City of Cupeorm against
liabilities,judgments, costs and expenses which may in any way accrue against said City
C AIR HANDLING UNIT (TO 10,000 CFM) 40�
is,cote of she gmma of this Permit,
a
AIR HANDLING UNIT (OVER IB000CFM)
a
S,glffura of Apnm/Contractor Data
EXHAUST HOOD(W/DUC�
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSUR
Data Receiptp
Will the applicant or future building occupant store or handle harundom material
us defined by the Cupcmino Municipal Code, Chapter 9.12, antithe Ilcahh end Safety
HEATING UNIT (OVER IIXI,f(If BTU)
'A'
CdA Section 235J2(e)?
13
❑ Yes 11 No
VENTILATION FAN (SINGLE RESID)
GV
ISSUANCE DATE
Wilhheepplicum or future M1uildingoccupant use<yuiparent ordevices whichemit
treatment air contaminants as defined by the Bay Am Ah Quality Management
Deaths?
BOILER - COMP (JUPOR IW,(NgBN)
P 0
BOILER -COMP (OVER 10B,gIB BTU)
❑ Yes ❑ No
FEB 21993
NEW RESIDENTIAL MECR. SQ. FT.
I have read the havadous materials requiremun
ems der Chapter 6.95 of the
California Heddh & Safety Cede, Sections 25505, 25533 and 25536. I understand Net
y
it the building does not cuilemly have a rent, that it is my responsibility to notify the
occupant of the requirements which most he met prior to issuance of a Certificate of
CITY Vr wren - ..w
Occupancy.
ISSUED BY: •�✓'•
Owner or adonced agent Date
L:
OFFICE