24454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT — 24454
PLUMBING-MECHANICAL,
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.AF.
T
•�i/u s AuW UNIT# LOT# (6-qt
PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
RC fl'ECT/li GINE LIC NO: ADDRESS:- AW ❑
CONTACT:i/I•�_ �� ONE:
_ ��/�/��(� Q QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�� I � "� 1� v�' PERMIT ISSUANCE `� BLDG - ELE PLUM MF.0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPTION
pCEC IM17000)of
mision 3 of
fthnsedinssand rifesions Codr and mmencise with � A/
00 fail foreandefOivmsion3of the Business end Professions Code,and my license 11 1. I UP 0S
y�� fullforecund ellen. UP T0200AMP5
GG W License Class Lic.N
ti y Date Convacmr 201-1000 AMPS
Z FOy^ ARCHITECTS DECLARATION OVER TWO AMPS ySQ.•FT.FLOOR AREA $/SQ.IT
O N.,O 1 undersand my plans shall be used as public records. C � J _ 4i
g� Licensed Professional - I - S A ) i``1(�Jr (• fG�y.//)I
Dt I wan exempt
RmDECLARATION SPE IAL CIRCUI /A1I9C. 6v �.
�yyX4OaF I hereby affirm that I rte exempt from the Contractor's License Law for the L b
W'3 W so following reason.(Section 7031.5,Business and Professions Code:Any city or county .METER 6 1 S
�ElOro; which requires a permit to construct,alter,improve,demolish,or repair my structure
� prior o its issuance,also requires the applicant such permit to file a signed satement POWER DEVIC
W 5 G O that he is licensed poromm m the provisions of the Commcmrs License Law(Chapter
2 0 9(commencing with Section 0000)of Division 3 of the Business and Pcouseimns Cade) S w a� VALUATION OO
on hat be is exempt therefrom and rhe basis for the alleged exemption Anyviolation d ' I V
<
Section 7F31,5 by any applicant fora permit subject.the applicant m a civil Penalty of OUTLETS-SWITCHES-FIXTURES `J JyV� _+
ig
not more than rive hundred dollars($500). NEW RESIDENTIALELECB _SQ.FT. STORIES TYPE CONSTRUCTION
❑ I,asownerofthepmperty,ormyemployeeswithwagesastheirsolecompensation.
3 wiRdo the work,andthestructure isnot intended oroffered fertile(Sea]M4,Business
and Professions Code The Conmetors License Law does not apply to an owner of
property who builds orimprovesthereon,a adwhodoessuchwark himselfmthroughhis OCC.GROUP RES.UNITS
own employees,provided that such improvemetsnare not intendedor offered for sale.If,
however,the building or improvement is sold within one yea ofeampletion,the owner- L
builder will have the burden of proving that he did not build or improve for purpose of
La mvecauftheproperty,am exclusively contracting with licensed contrsetorsto QTPLUMBING PERMIT FEE FLOOD ZONE APN
c us the project(Sec.7044,Business and Professions Code:)The Contactors ^
se Low doesnotapply loan ownerofpropony who builds or improvestherecn,andPERMIT ISSUANCE
mcentructs forsuch projeea with aeontmetor s)licensed pursuant to the Comrefore 1
License Law. \ ALTER-DRAIN&VENT-WATER(EH 0—.a FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ES
SANITARY Y N
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Thereby affirm the lhaveuecrtifcem of consent mself-insure,ora certificate mf FIXTURES PER.I.RAP RECEIPfp
Workets'Comaismadon Insurance ora certified copy duccomf(Sec.3900,Lab C.)which PARK FEE N
covers all employee's under this permit GAS-EA.SYSTEM, E IPI#
Policy# ILDING VISION
FEESI INC.4 OUTLETS
Company GAS-EA.SYSTEM-OVER 4(FA) PLA
❑ Cenifed copy is hereby furnished.
❑ Certified copy is fled with the city inspection division. HEIISEONDUSTRL WASTE INTERCEPTOR GRADING FIE
;T�
CERTIFICATE OF EXEMPTIONFROMWORKERS' GREASE TRAP SOILS FEE
COMPENSATIONINSURANCE
(This section needimbe completed Hire permit is far.hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEEor less.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELECIRnot employ any Person in any m os to become subject to the Worker' PAID
O z CpoorriamnsitionLawsofCelifomia. Date eo WATER SYSTEMUREATTNG Datnt
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.r/] become subject to the Worker's Compensation provisions of the Labor Cade.you mustBUILDING FF;F:forthwith comply with such previsions or this permit shall be deemed revoked.ZCONSTRUCTION LENDING AGENCY SEISMIC FEE tooI hereby affirm that there Is a construction lending agency for the performance ofELECTRIC FF.EO the work for which this permit is issued(Sec.NEE.Civ.C.)Lenders Name
0ULinder.Address QTY. MECHANICAL PERMIT FEE PLUMBING FSI«nify the[1 have seed this application.nd sate that the above information isMECHANICAL correct.Iagreemcomplywithallcityand county ordinaces andsate lawsrelming 0 P&MIT ISSUANCE "^�building construction,and hereby authorize representatives ofthis city to enter upmhe CONSTROCTIO
(� 51
'Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. ��
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmen osa and expenses which mayin up ywayaccrueagainstsaid City AIR HANDLING UNIT(TO 10,000CFM)
in cunuquenc t granTng of this '//�/$
lz/�-/IYI�I AIR HANDLING UNIT(OVER 10.000 CFM)
Sig rare of Appe.uEapplossaw Date EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS BOccupMATERIALS DISCLOSURE
HEATING UNIT(TO IW OW BTU) Date Receipt#
Will the appCcanmr(u[ure building occupant store or handle hazardous materiel HEATING UNIT(OVER IOq(KKI BTU) T
as def red by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety �^ EN
Code,Section 25532m)? ISSUANCE
FAN(SINGLE RESID) zals
❑Yes ❑No
ISSUANCE DATE
Will the applicenwrfuturebuildingmcupam useeyuipmenlnrdevice.which emit BOILER-COME(3HP OR 100,000 BTU)
'itazadous air contaminants as defined by the Bay Area Air Quality Management
Distric@ _ EOILER-CDMP(QVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. Ip p Pi I D
I have read the hazardous materials requirea enunder Chapter 6.95 of the 1�
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undersand that
��
if the building does not currently have a tenant,that it is my responsibility to notify the 17 1('93
occupant of the requirements which which must he met prior to issuance of a Cerifcme of 3
Occupancy.
Owner nrauthorizedagent - Date TO IS$UBO01:��
OFFICE