24652APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO n L .- -LLCTRICAL
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING -MECHANICAL
_'.'4BUMDINGPROJECI'IDENTIFICATION
PERMIT NO.
24652
BUILDING ADDRESS:
ZI I `Y�U v�v UNITM LOT#
SANITARY NO.
A1PPUCATIONSUBMITALDAT.
`-��2
OW `NA E: �s y# I�� PHO`flE;_��y/w
/��-11( Z(JZ yy
CONTRACTOR'S NAME: LIC NO:
NIC
❑
TCONTROLq
RCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
.;;tit' - - ay,;ypr', ;,,":i
QTY.--_y,::,•;`„y ELECTRIC PERMIT A,. ;, FEE :_
"BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
E] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affw dontlam licensed under provisions,dC'hapter9(commemingwith
APPLIANCES -RESIDENTIAL
309 DESCRIPTION
Section 7000) m Division Jaime Boxiness ant Professions Code, and my licaue is in
PANELS
full fmce and effy,. Zit
Limit C2lara�CC-..rte"'{—Lie.M 7UPT02MAMPS
Dale Contractor r ” 3'!' �J�
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used as public record
OVER 1000 AMPSLS
.�LQ1n�'RAt ■
IC. J
$/SQ. PT.
SIGNS ELECTRICAL
p
"u
Licensed Professional
ER
OWNER-BUILDOECIARATION
SPECIAL CIRCUIT/MISC.
P 4-J, E R
I hereby affirm Nat 1 am exempt Gam the Commerce, License Low for the
following person. (Section 9031.5. Business and Professions Code: Any city or county
TEMP. METER OR POLE MST.
which requires a monis to coowc4 alter. improve, demolish, or minor any structure
prior its issumedalso requbo the applicant for such permit to file a signed intention
DATE
POWER DEVICES
thin he is licensed pursumt to the provisions of the Contractors License Law (Chapter
9(commencing with Section 70001of Division 3 of Ne Btuinm and Formal..Code)
m that he is exempt therefrom and the basis for theallegW exemption. Any violation of
Section 7031.5 by my appHeanr for a permit subjects the applicant m a civil penilny of
SWIMMING POOL ELECTRIC
'20 VALUATIO�
!0 {A
11""..77 V
OUTLETS - SWITCHES - FIXTURES
no, more Jun five hundred dollars ($500).
❑ I.uownerofNeproperry,mmycmploycawithwagonsheirsolecompe m.
NEW RESIDENTIAL ELECIR _SQ. FT.
STORIES
TYPE CO. STRUCIIOJ
will dothe wort.andrhe moo me Is not Incendcdmoffend for We (Sec. 7066. Business
and Professions Code: The Contractors License Law does not apply to an owner of
property, who mildamimprovotherton,and amdowimchwmk himealfir,domghhis
wnemplaym,providW that smtsere himprovemcnnot inundedoroffertdforule. If,
OCC GROUP
RES. NITS
TOTAL:
how<vec the building orimpronment isuld within one Yemof compinion, theowner
huilder will have th<buNen of proving that he did ms build m improve fm purpose of
QTY ;.(i 'PLUMBING PERMITl�'} riFEE-i';{
_��a. ;• ti..__. n.
sale.).
❑ Lasowneroffhe property.ameadvsivelymnm4ninB with )teemed canvu, to
FLOOD ZONE
APN
continues The projes, (Sec. 7064. Bmineu and Professians Code:) The Canvacmra
License Lhw dins not apply tom owner of progeny w ho bu ilds m improvo thereon, and
PERMIT ISSUANCE
whocmnacts fmmch projects with acomactor(M licensedpunuanundu Coinmctors
License Law.
ALTER-DRAIN&VENT- WHIA)
- .'r. _
"k":,+^:'-,..,T.hsFEE SUMMARY
❑ 1 am exempt under Sec . B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE
SANITARY Y_N
RECEIPT#
Owner Date
pRA1N5-FLOOR, ROOF, AREA. GOND.
WORKMAN COMPENSATION DE ON
SCHOOLTAX YN_
❑ Ihertby effitm,harlhav<a ttrtificata o(camcm bull-insurt,macenifi<am of
Worken'Compensatim Wumnce or a certified copy banner (Sm. 3800, Iib C.) which
coven ell emplo is
Policy It a
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
RECEIPT
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
y
Company L V
GAS. EA,. SYSTEM -OVER 4IRA)
PLANCHECK FEE
❑J CemfiW copy is hemby f ro fished.
GREASPANDUSTRL WASTE INTERCEPTOR
GRADING FEE
yp Cenifiesim y is filed with the city mimetic. division,
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER- SANITARY - STORM EA. 2Wn.
ENERGY FEE
(This section need not be completed if Ne permit is formic hundred dollars($IN)
or less.)
WATER HEATER W/VF.NT/ELECIR
I certify Jur inthe perfomsmm of the work forwhich Nis Fort is issued. I mail
not employ my person in my manner m as to become subject to she Wromrs'
Compertution Laws of Ca ifomia. Dare
PAID
Dam Receipt #
WATER SYSTEM/IRF.ATING
Applicant
NOTICE TO APPLICANT: if, offer making thu Certificate of ExemPtim, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTA.
become subject in no Worl CompernaSim provisions of the Labor Code, you mus,
forthwith comply with such provisions or this permit sluff be deemed revoked.
BUILDING FEE
fe
SEISMICFEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a commuc,im lending agency forme performance of
the wink for which this Fermi, is issued (Sm. 3092 Civ. C.)
TOTAL
ELECTRIC FEE
sex ••• vrJ„w.4.vw:.r .e avyt. rt�I* r �+'fFEE:�'' S
QTY. ,,-p'hfl!CHAMCAl PERMIT
s"`T TY-' `' tc•N`i5f "):., rzhs- :*
PLUMBING FEE
Ierufer's Name
Lender's Address
1 mnlfy that 1 have tad this application and suite that jr. above infarvution is
coven.lit,weee comply with allay andmarmyordinances andenre laws relmingee
' - ,r _
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorise representatives of this city eeeiner upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
-
AIR HANDLING UNIT(TO IBM CFM)
(We) agree to save, indemnify and keep hawless the City of Caperton agui of
Iiabilitia.judgmeth, costsandexpensn which may in anywayompre against said City
AIR HANDLING UNIT (OVER I0.000 CFM)
in consequence of the graining of this permit.
EXHAUST 1100DIW/DUCD
PAID
Sign" o Cu or / Dae
HEATING UNIT (TO 101,000 BTU)
HAZARDOUS M (ALS DISCLOSURE
Dae Rettig#
HEATING UNIT (OVER 100,000 BTI))
TO 1AI'
1 sv
Will the app)icant or future building mcupanf seen or handle hr mdous material
as defined by the Cupertino Municipal Code, Chip., 9.12. and The Health mJ Sure,
Code. Section 25532(.)!
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will meapphearamfnti. buildingmcvpmsuseequipmen..rdevicowhichemit
BOILER- COMP(3HP OR 100.000 BTU)
ri 1
'haa4rdom au cmmor ants as Jetirm by sbe Bay Ana Air Quality Management
BOILER - COMP(OVER 100,000 BTU)
District? ❑
❑Yes No
y
JAN ..4 ac-,
NEWRESIDENTIALMECH. SQ. Pp.
1
I have mad the huardons materials requirements under Chapter 6.95 of the
California Health & Safety Code. Sections 25505,25533 and 25534. 1 understand than
Li7fr 'Y
if the building does not currently have u nnom, that it is my responsibility to notify the
cupann of Ju reyuiremenn which man he m<, prim m ivumce of a Cenifinm of
O
(Xcupancy.
ISSUED BY:
Owner or awhonred agent Date
TOTAL:
OFFICE