24522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. w
APPLICATIONIPERMIT PLUMBING-MECHANICAL. L 'LJ
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
tlDILDING AUDRFSSM SANITARY NO. APPLICATION SUBMITTAL DATE:
V O S LOT 4 1� /1
CONTRACTOR'S NA LIC NO: �7
_ N/C CONIROLN
"1
ARCHCT
ITE '/ENGINEER: LIC NO: ADDRESS: ElL Sat
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOCLE PLUMB El
PERMIT ISSUANCE — -IF
LICENSED CONTRACTOR'S OECIARATLON APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensed under I (Chas 9(commencin th LOB DESCRIPTION
q00 yu pavrofeso per eis
LL100 Section](plB of Diviaion7 of she Business and Professions Code,and my license is in PANELS
,UE full force and effect. T
FZW License Class Lic.N UPT02MAMPS
w=y Date Contractor 201-IIXxI AMPS 5 ff.FLOOR AREA $/SQ.I4.
ZOy4 ARCIIITFCTS DECLARATION _ OVER I(IOOAMPS Q'
O Z�Appp I understand my plans shall be used as public records.
G y�� SIGNS ELECTRICAL
6 fy� Licensed Professional
c�.0Iz1U OWNM- DECLARATION SPECIAL CIRCUITIMISC.
xOa 1 hereby affum that I oto exempt(nam the Contrectors License Law for the
W :LLE- following reason,(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to conssae,alter,improve,demolish,or repair say structure
;!
= 7 prior to its issuance,also requires the applicant for such permiuo file aligned statement POWER DEVICES
ry�j <Om that he is licensed pursuant to the previsions of the Contractors License Law(Chapter
9(comaeraing with Seelam 7000)of Division 3ofthe Business and Profeuions Code) SWIMMING POOL ELECTRIC VALU]'Qt]y
yI_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation ofCJG�
Q
Section 703 LS by any applicant fora permit subjecm the epplicam toacivil penahy of OUTLETS-SWITCHES-FIXTURES List J ��
not ore than five hundred dollars(5600).
NEWRPIDNIALE=R 5 .F`L
, sownerofihepropny,ormyemployeeswihwagcsothelnolecompnsation, STORIES TYPE CONST RUCTION
n11 e work,and theswctme isanl intended oroffered prsale(Sec.`? 4 ,Business
no Professions Code:The Contractor's License Low does not apply to an owner of
papery whnboildsorimproves thereon,and whedocssuch work harselforthrough his
own employeea,provided thatsuchimprovememare not ancrleduroffcred hostile.If, OCC.GROUP RES.UNITS
however,the building or impmvemem is sold within one yemofcompleion,the owner- TO L
builder will have the burden of paving that he did not build or improve f n purpose of
mile.).
❑ I,asownerofthe property,mneaclusively convecting with licensedconuvntoito QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct she project(Sec.7044,Business and Profcssivx Cade)The Commcmr's
License Lawdrerretepply toanowncrofproperty who builds orimprovesthereon,and Pf:RMIT ISSUANCE
whoconvacts forsuch projects with aconommhd licensed pursuant to the Contractor's ALTER-DRAIN&VW
VENT PA
License Law. ( ) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this reason S
BACK FLOW PRtYfECT.DEVICE SANITARY YN
Owner RDateAT - RF.CFIPI'p
DRAINS- OOR,ROOF,ARIA,COND.
WORKMAN COMPENSATIONDECLARATION C LTAX Y N
❑ Thereby affirm that have aceni0eae ofconsenno self-insure,orecenifcae of FIXTUREPI RF.CEIPfp
aWorkers'Compemation Insurance macenified copy shetenf(Sec.HIM,Lab CJ which C. I IRARK PRE Y N
ersall employee'a under this permit ECE 'N
GAS-CA.SYS INCLO TI T
PnlicyN BUILDIN TVI ON FEES
Company GAS-G.SYS -OVFR`4(F:A LAN IIECKFEE
❑ Certified copy is h,od y famished.
❑ Certified copy is filed with the city inspection division. GREASflANDUSTRgyAVEINT.RC: A Z GRAD GFEE
CERTIFICATE OF Ii HMPI'ION FROM WORK MSGRFASHTRAP S FEE
COMPENSATION INSURANCE
(Thissection need not becompletod tithe permit is ferrone hundred dollars($100) SEWER-SANITARY-STORM EA.200FI'. ENERGY
or less)
I certify that in the performance of the work for which this permit is issued,l shall WKITR HEATER W/VENTfRLECR
not employ any person in any murder an in to hecome subject to the Workers' PAID
z Compenutionlawsof California. Dam WATER SYSTEMOREATINO st Da Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this Cenificele of Exemption,you should NEW RESIDENfI AL PLMB. SQ.Fr'. TOTAL-:
V) become subject to the Worker's Compensation provisions of the Labor Code,you most
; forthwith comply with such provisions or alts pemaii shall In deemed revoked.
0 CONSTRUCTION LENDING AGHNCY 'ISMIC '
z 1 hereby affirm that them is a construction lending agency for the perfemtance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
1,a der s Name PLUMBING FEF.
O r1<nders Address QTY. MECHANICAL.PERMIT FEE
U I certify aha I hove read this application and state thm the above information is
>"' 12.1contest.l agree to comply with all city and county ordinances and stay laws relating m PI?RMI'I'ISSUANCE MECHANICAL FE
F^ y building construction,and hereby authorize representatives ofshis city to enter uponthc - CONSTRUCTIONI X
Uabove-mentiueed property far irupeclum sur,mxes. ALTER OR ADDTO MECH.
(We)agree ni" ' demnify and keep haat, the by of upenme against
liabilities.' oils man pea.awhi.h yi any i eugainn said City AIR HANDLING UNIT(TO 10,000 CFM)
me Jk
ting ispe it.
AIR HANDLING UMI'(OVER 10,000 CFM)
ata wnv trust Dam EXHAUST HOOD(W/DUCO PAID
k0005 MATERIALS DISCLOSURE
1[EATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,1100 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety //lytd�
Cale,Section 25532(,)9
13 Yes E)No VENTILATION FAN(SINGLE RESID) V
ISS NCE DATE
Will she applicantorfuturebuildingoccupansuse equipmemswh
ordeviceich emit tlO1LIiR-COMP(JHP OR IIX7.IXNI BTU)
• huzurlous air conamirenss as defined by the Buy Area Air Quality Management HOILER-COMP(OVER 100.000 BTU)
Diso-im?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT, gy A 1
I have read the haaudims nouncols requirements under Chaplet 6.95 of the - V' Pr1
Califomis Health&Safety Code,Sections 25505,25533 end 25534, 1 understand shat [[''(/7�
If the building docs not currently have a tenant,that is is my responsibility to ratify the ®T„u sjj 21992
occupant of tae mquiremems which muss be met prior to issuance of a Cenifican,of
Occupancy. ((��
Owner or notherized agent Dale TOTAL: ISSUP.6I BY: 1F -t 51
OFFICE