24728APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY �P CUPERTINO
BULL DING-ELF.C'TRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT]DENHFIAI.
BUILDING PR(AECI'IDRYTIFICNyUN
PERMITNO.
24728
BUILDINGADDRISS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
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CONTACT- PHONE:
QTY. ELECTRIC PERMIT FEF,
BUILDING PERMIT INFO
BLDG F.PLUMB MFCH
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PERMIT ISSUANCE
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� ICY.El
1:1 El
LICENSED CONTRACTOR'S DECLARATION
I hercby eff on Nat l am limen ed under provisions of Chaptcr 9 mm
(coencing with
Section 70Division 3.fvhe Business end Professions CM,, and my license is in
8(0.(
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
full force and effect.
wi
License Class Lic.p
UPT02MAMN
Date Contmclor
201 - 1000 AMPS
ARCHITECTS DFCLARATION
1 understand my plans shall be used m public records.
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER IM AMPS -
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm for I am exempt from the C.nuadm's License Law far the
TEMP. METER OR POLE INST.
following reason. Posts.. 7031.5, Business and Professions Cade: Any city or comfy
which requires a Permit to concoct, alter, improve, demolish, or repair my structure
prior 1. its icursure. also rcquiresthe applicant fnrsuch permit to fileusigned statement
POWER DEVICES
that he is licensed pursuant to the Provisions of the Contractor's License Low (Cbepla
9(commencing with Section 7")of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or Not he is exemptaherefromandthc bris fartheelleNd exemption. Any vidina id
Section 7031.5 by any applicant (oro permit subjects the applimm m a civil penalty of
O 1
not most then five hundred dollars ($5001.
❑ Los.corset.fNepropery,ofmyemployceswithwagesasiheirsolecompensution,
N11 I I
STORIES
TYPE CONSTRUCTION
will do the work, and the stmetum i snot intended or o ffcml for safe ( See. 7044, Business
and Professions Cade: The Contractor's License Lew does nm apply w an owner of
Palmy who builds or improves themar, and who does such work himself or through his
employees,provided ohm such improvements orenminendedorofPorcdforsale. If,
,DATE
OCC.GROUP
M. UNITS
- TOTAL:
however, the buildingorimprovement is sold within one yearofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ Lasownerofthepropeny, amexclusively contracting with licensedeommcton to
FLOOD20NE
APN
comtma the project (Sec. TIH4, Business and Professions Code:) The Cmarm, is
License Lawdess not applytoanownerof tai any who builds or improves thermn, and
PPRMIT ISSUANCE
whoc.ntnca f.rsuch projects with ammusete s) licensed pursuant ns the Contractor's
License Law.
pLTEN -DNAIN&VENT - WATER (1?A)
FEE SUMMARY
❑ 1 tors exempt under Sec. , B & P C for this rcdson
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT X
Owner Data
DRAINS - FLOOR, ROOP,ARIiA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y _ N
❑ I hereby affirm that l have a ceniftcale ofeamentto self-insure,m a mnificam of
Workers' CumpetwYon Insurance or a emitted copy thereof(SecJBlp, 1<b CJ which
RECEIPTif
FIXTURES - PER TRAP
PARK FEE Y N
n all employee's under his permit.
Policy a
GAS - EA. SYSTEM -1 INC. OUTLETS
RECEIPTH
BUILDING DIVISION FEES
Company
❑ CenifiecimpyishersbyfumishaJ.
GAS, EA. SYSTEM -OVER 4 (FA)
PLANCHECK FEE
GRGSEIINDUSTRLWASTEINTERCEPPOR
GRADING FEE
❑ CenifiedeWy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be, completed ifthe permit is f.rove hundreddollars (5100)
orless.)
WATER HEATER W/VE.NTIFLECIR
I certifythav in the performanceof the work for whicl permit is issued, Ishalt
not employ any person in any manner so as to become subject to the Workers
PAID
WATER SYSTEMAREATING
Compensation Leasof Califorda. Date
Date Receipt#
Applicant
NOTICE TO APPLICANT, if, after making this Cerificateof Exempllon, you should
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
became subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performance of
the work for which this Permit is issued (Sm. 3097. Civ. CJ
ELECTRIC FEE
Lendds Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I certify that 1 have read this application and some that the above information is
correct. l agree in comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingrnnsvu ' ,and hereby auhorize mpresentmivesofthis ivy m enter upon the
above-mmf -r_ perry for inspection purposes.
ALTER OR App TO MFCH.
CONSTRUCTION TAX
(W agree save, indemnify kcep harm? eCiry of Cupcnin against
liebiliti ,jud Je swhic any way accmeagain said Ci
AIN HANDLING UNIT (TO IO,IXp CFM)
AIR HANDLING UNIT (OVER 10,(00 CFM)
it equc tin /
EXHAUST HOOD(W/DUCT)
PAID
Si m .fApplicant/Conttaztor
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dale Reccipttl
HFATINGUNIT(OVER M." BTU)
AL:
Willthe.,hrum or furore building occupant score ar handle harudous material
as defned by the Cupertino Municipal CMO, Chapter 9.12, and the Health and Safety
Code, Section 25532007
❑ Yes 11 No
VENTILATION VAN (SINGLE NESID)
BOILER- COME LHIP OR 1(0,000 BTU)
P A I1$$UANCE DATE
Will theapplimmorfmurebaildingouupent use cquipmenmrdeviceswhichamit
BOILER - COME(OVER 100,000 BTU)
hazardous it contaminants ns defined by the Bay Area Air Quality Management
District?
1-1yen❑ No
NEW RESIDENTIAL MECH. SQ. FT.
'I
N 9 IQ93 �ay�
JAN 2 IV v
I have reed the hazardous materials requirements under Chapin 6.95 .f the
dn1tl
California lfeahh&Safety CMe,Seai.ns25505,25533 and 25534. Imsentundlhat
^ITi GUF'CtII ou
if the building does not curently have a mount. that it is my responsibility to notify the
1 Ur
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
IISSUED BY:
Owner tar amhorized agent Dae
TOTAL:
OFFICE