24509U
19
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO H 1LDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDEN'PIF'ICA'TIO
PERMIT NO.
/� A4 J CO
GN
BUILDING ADDRESS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
hJ i�TV� •I�� UNIT at LOT Is
` ���/// "`���•���
PHONE: /
'253 /b
J
CO TRACTOR' N h: I.ICNO:
A _ �7
A -a J
NIC
❑
CONTROL#
A C - /ENGINHER: LIC NO:
ADDRESS: �_ y'
237 Iv
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMI'P INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
Cl IGT F-1 11
LICENSED CONTRACTOR'S DECLARATION
(hereby affirm that] E IKON under provisions of RATE 9(wmmencing with
Section7(=)of Division 3dithe Bminecaand Professions Cale,and my license is In
full force and effect.
AppLIANCFS- RESIDENTIAL
]OBD CRIP[JpJJ
\f�7
PANELS
License Class Lid, If
UP TO 200 AMPS
Dam Contractor
20[. IOW AMPS sitar
ARCHITECPS DECLARATION
1 understand my plana shall be used as public records.
OVER FOR AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
SIGNS ELECTRICAL
A L E D N
Licensed Professional
OWNER-Bempt
SPECIAL CIRCUIT/MISC.
hereby affirm that I am exempt from the Contractor's
fromtheLicense Law for the
l
TEMP. METER OR POLE ]NST.
follow1 Co
and Professions Com: Any city oometury
t
f� /7
aPermin.
whichi"hirdsng
s n permit to construct, alter,
c alma improve, demolish, repair any nmraum
Y
® uvl T R
poor to as iss a inesrdoe
pri�rmits issuancq also requirestM1<aPPlicont for such pemduo fileasigned samment
fi
POWER DEVICES
that he is licensed pursuanuo the provisions of the Communes License Law (Cheaper
9(commencing with Section 701of Division 3 ofthe Business and Professions Code)
V L
SWIMMING POOL ELECTRIC
or that he is exempt therefmm endthe basis for thenllegW exemption. Any violation of
Sen ion 9031.5 by any applicant for a pemtit,objects the appliama to u civil penalty of
OUTLETS-SWI'fC11F.S-FI%'1'URGS
not more thon five hundred dollars ($500).
❑ I,nownerofthepmpmy,ormyemploy«swithwagesmtheirsolecompensation,
NIIWRFSIDEITIALELECIR_SQ. FT,
STORIES
TYPECONSTRUCTLON
wi I I do the work, and the souctu re is nm i mended art of fema l for sale (Sec. 7044, Business
and Professions Cale: The Connucmr'a License Law does not apply to un owner of
property whobuildsor improves thereon, and whndnes such work himaelfor through his
employees,provided that such improvements are not inendedoroffcred forsale.If,
OCC. GROUP
RES. NITS
1
however, the buildingorimprovement is sold within one yearofeompletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
Qom' PLUMBINGPERMIT FEF,
sale.).
❑ I, ns ownerofthe propeny,am eadusively commcting with licensed commelon w
FLOOD ZONE
APN
em ... t el the pmjeet (Sec. 7044, Business and Professions Cane:) The Contractor's
License Law does nm apply to an owner o f property who bui ld s or im pmvea Cher mn, and
PERMIT ISSUANCE
who etmBncu for such pmjecu with u commustogs) licensed pumuatuo the Connownes
License Law.
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Saw. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
--
15UTSIB-IFFES
Y
SANT' N
RECEi1PTp
Owner Date
DRAINS - FEOOR,ROOF, ARFA,COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ T hereby added that l have a candidate ofconsento self -insure, or a certificate ofIIXTURFS
Wcrkers'Compartati r, hotmence oraeenified em,ffiereof(Set. 3800. Lab C.) which
RECEIPT#
- PLR'IRAP
PARK FEF: Y N
covers all employee's under this permit.
Policy p
RECRIPT p
GAS - EA. SYSTEM -I [NCAOUTLETS OUTLETS
BUILDING DIVISION FEES
ComPaty
GAS - EA. SYSTEM OVER 4 GiA)
PL.ANCIIECK FEE
citified copy is hereby fumiWed.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXI3MPTEON ]BOM WORKERS'
GREASE'I'RAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM FA. 200FT.
ENERGY FEE
(This section need not bedumpleed ifthe persail is foron hundreddollan($100I
or less.)
WATER HEATER W/VENT/ELECIR
I certify that in the performance of the work for which this permit is issued, l shall
o
nm employ any person in any munadr s as to become subject to the Workers'
PAID
Compcnaim Lawsnf Culifomia. Data
WATER SYSTL'MITREATING
Data Receipt#
Applicant
NOT ICE TO APPLICANT: If. atter making this Cmifcam of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. IT.
TOTAL:
become subject to the Workces Compensation provision of the Labor Cede, you nun
forthwith comply with such provisions or This permit shall be deemed revoked.
BUILDING FEF.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm then there is a construction lending agency for the performance of
the work for which this permit is issued (Sed. 3097, Civ, C.)
Lender's
TOTAL:
ELECTRIC FEE
Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify Our 1 have mastiffs application and sum that the above information is
correct. l agree to comply with all city and county oNinmua and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingeonstructim, and hereby authorize representatives ofthis city he some upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECIL
CONSTRUCTIONTAX
(We) agree to time. indemnify and keep harmlesa the City of Cupertino against
liabilities' Iscc and expenses which may in any way accme against said City
A IR HANDLING UNIT (TO I BAR CFM)
in ce ce of he gmntinB of is permit.
AIR HANDLING UNIT (OVER ULXsd CFM)
Ignuurcs pplicum/Commcmr Date
EXHAUST HOOD(W/DUC)
PAID
HEATING UNIT (TO loo,f100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam 'Receipt#
Will the applicant or future building occupants start or handle harmdous material
as defined by the Cupertino Municipal Cale, Chapter 9. 22, andnhe Health and Safcty
I]RATING UNIT FOV ER 100,1130 BTI)
Cale, Section 25532009
E, Yes 8 No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicam or fuwmbuilJingnccupant uaeequiprrmmordeviceswhich emit
BOILER - COMP (3HP OR 100,(1(10 BTU)
BOILER - COMP(OVER 100,000 BTU)
harmdtus air connotations as defined by the Buy Area Air Quality Management
District? 12 Yes Of No
B
NEW RESIDENTIAL MECH. SQ, FT.
I have read the htmohms materials ea3uinemcros under Chapter 6.95 of the
California Health & Safety Co23
Code, Sections 23505,V5533 and 25534. 1 understand that
p� y n V
IdO� 3 19,92
w
if the building does not emmody have atenant,that it is an, responsibility to notify the
wmt f the requirements which must be, met prior to issuance of a CmJficam of
uryo
/s t�YY
CITY QiCVI'tCT1
Occupancy.
�y���
ISSUED B;J I/M Y /
Owntt or emhorircd agent Date
TOTAL.:
OFFICE