24891 'f APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
k� CITY OFCUPERTINO B IIAING-RLECfRICAL PERMIT NO,
APPLICATION/PERMIT PLUM ROJECTI?CHANIFIC 24891
BUILDING DIVISION BUILDING PROJECT URN'1'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA11ONSUBMITALDA1E
/o6_3 .UNIT# LOT If
OWNERS NAME: PHONE: CONTRACTOR'S AMG: _LIC :
N/C CONTROL#
NO
fe
ARCHI'MC1YENGINEER: LIC NO: ADDRESS: S, ❑
C
corrrncr: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MUCH
.MITT-' ANCE 1:1 ❑
LICENSED CONTRACTOR DECLARATION XIIIJANCES-RESIDENTIAL
Ihereb USE.that lamlicensal under JOB UESCRIPf ON
OC2 hereby proviaion.me Crat.scal mmeneingwith ��
W WUE Section
llfiao.�]fKq)euf`DivisinnJ.f the Basin esxla dProfe/salons C,-a/]de�arm my license isu ppNE� IL
FQV� Lieeme lass I.ic.# `� a✓ _" • UPT02MAMPS
yW
y Date Contmetor 201-10011 AMPS
Fyz ARCHITECTS DECLARATION
SQ.FT.FLOOR AREA Sm.FT.
OZ—ClH Cl I understand my plans shall be used as public racordx. OVER IOW AMPS
O
Q �
y t W SIGNS ELECTRICAL.
Licensed Professional
tgJ < OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOm V I hereby efOrm m that I aexempt from the Contractors License law for the
an-vFi following reason.(Section 7031.5,Business and Professions Code:Any city or county I' 1W.MTT iR OR POLE INST.
which requires a permit to comtmct,alter,improve,demolish,or repair any structure
p.� primmisi.......Is.requires Neappllcantformch permit to file.signed statement WF.D
W K CC) that he is licensed puramet to the provisions of the Convectors License Law(Cbaprer
aao� 9(commencing with Section 7000)ofDivisiun 3 of the Rusinexs antl Professions Code? IMMING POOL CLECI'RIC VALUATION
_y onhathe is exempt therefrom and Ne basis for Nealleged eaempsion.Any violation of OUTLETS:SWITCHPS-FI RES 1
> Section 7031.5 by any applicant for a Permit subjects the applicant to o civil penalty of
Cnot mom than live hundred dollars(E50% //��a""��
m ❑ Lmawxrof N<property,ormyempinyeeawilhwageamtheirsolecompenserion, NEW.p eNTIAL[: STORIEZ TYPECONSTRUCDON
a3— will M the work,amd the structure isnot intended.,offerW for sale(Sec.70414,Business ,
and Professions Code:The Connectors License law does nm apply to an owner of
property whobuildsorimproves thetcon,umdwhodocasuch warkhimselforthroughhia OCOGRO P RES.UNITS
ownempl.yees,provided Natsuchimprovemonsatenot intende ioroffered for sale.If.
however.the building or improvement is sold within one yearnfcompletion,rhe owner- TOTAL;
builder will have the burden of proving that he did act build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE MOODZONE APN
n
❑ I,in ruftlm property,an exclusively contracting with licensedconmacton to
onxlruct Shepmjecn(Sec.704d,Business and Professions Code:)The Contractor's
License lawdoesnot applyto anownerofpropery whobuildsorimproves Shearon,and -PERMIT ISSUANCE.
whocomects forsuch projects with acantractor(s)Iicemedpursuamtothe Contractor's
License Law. ALTER-DRAIN&VENT-WATER(FA) FRESUMMARY
Ourisffiffrm
s(-. ❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affrm nhanl hnveecerrificate of consennn selGinsure,oracenificaa of FIXTURES-PER THAT RECF.IPfp
Workanx Comperestion Imuenceofa ceraficd copy thereof(Sec.JAW,lab C.)which PARK FEE Y_N
c.vere.11 craft d t ' RECEIPTq
Policy N
9 EY Y9 GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Compatry� �a s mow_ - - --- GAS-EA,SYSTEM-OVER4 SEA) PLANC IECK FEE
Certified copy is hereby famished.
Certified copy is filed with the city impedion division. GREASUINDUSIRL WASTE INTERCEPTORGRADING FEE
CERTIFICATE OF P.XEMPfION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completedifthe permit is forome hundred dollars($100)) SEWER-SANITARY-STORM EA.20JFT. ENERGY FEE
.r less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER WNPNgELECfR
not employ any person in any manner so as to become subject no the Workers' PAID
Compeasationlawsaf California. Date WATER SYSTEMHREATING Dote Receipt#
O z Applicant
z 2 NOTICE TO APPLICANT:If.after At., his Cenincata of Exemption,you should NEW RESI DFNfIAL PLMB. SQ.FT. TOTAL:
r CA become subject to the Worker's Compensation provisions of the Labor Cod,you must
F^ forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE �N
LLIQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hbyereaffirm In., I,.conawingctioo lendagency far the perfmarmse of
TOTAL: ELECTRIC
U O
the work for which this permit is issued(Sec.J097,Civ.C.)
Li. Lender's Name PLUMBING FTSE
Lender's Address QTY. MECHANICAL PERMIT FEE
UI certify that I have read this application and state that Sheridan, infomottion t. MECHANICAL FEE
>. {2a correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F" SI building construction,and hereby auNorie,represcnutiveso(this city to enter upon the CONSTRUCfIONTAX
Vabove-mentioned Proper,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino agmost
liabilibes,judgments,ceens and expenses which may in any waysccrueagvnst said City AIR HANDLING UNIT(TO 10,11011 CFM)
in mose namire of the Braining of Nis pmait.
AIR IIANDLING UNIT(OVER IQO(q CFM)
Signature of ApplicamAontractor Date EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO M,001)BTU) Date Receipt If
Will the applicant or future building occupant atom or handle hazardous material IIF,ATING UNIT(OVER IBIJKM BTU) TOTAL:
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Beath and Safety
_ - Cude,Section25532(a)? VENTILATION FAN(SINGLE RESID)
♦+ ❑Yes AN.
BOILER-COMP(311P OR 100,070 BOTH ISSUANCE DATE
Will the applicanmrfu[taro Wildingaccupannuuequipmenmrdevices which emit pp�� p
air contaminants as defined by the Bay Area Aft Quality Management BOILER-COMP(OVER SM."FITU) P A 9
t? .
us ❑Yea ANo NEW RESIDENTIAL MECH. SQ.PT.
have read the hmardous materials requirements under Chapter 6.95 of the MAR 23 1993
tllif nni.Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
i f the building does not currently have a tenant.that it is my responsibility to not the Clcupart of r y m ry h must be met prior to issuance of a�Certifificate f VI Y Ur Uta �/
Occupancy.//( :ire ern m s
Ownermi harindagen / 'a Dam TOTAL: ISSUED BY:
OFFICE