24594APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO24594
ILII - ELECTRICAL
PERMITNO.
APPLICATION/PERMIT-MECHANICAL
PLUMBINGING
BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
Cu°
'DE
�a w �O`t
SANITARY NO.
APPLICATIONSUBMITALDATH
`A23c)& ",zA C r2 IT#
11
UNIT# LOT#
\ 2—i aS�L
OWNERS NAME: PIIO^NE:
SV
CONTRACTOR'S NAM[r LIC NO:
g )
N/C
❑
CONTROL#
O AJ dS Z�� g
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ARCIIITF.CT/GNGINERR: LIC NO: ADDRESS:
I' siggs—'SAME
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE
19L ❑ D
LICENSEDCONTRACTOR'SDECLARATION
RAT(
APPLIANCES - RESIDEMIAL
BDFSCRIPTIOy_
I hereby affirI am licensed uACTORvisDECL
9(commencing with
srp$�,r�k`♦�'�i
Section 70A) of Division 3 of the Business and Professions Code, and my license is in
PANELS
full forte and effect.
License Class Lic.p
UP T02IXIAMPS
/sem
Date Contmanr
201 - I" AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
ARCHITECTS DECLARATION
OVER 1000 AMPS
1 understand my plans shall be used as public record.
SIGNS ELECTRICAL
Licensed Professional
OWNER.BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt from the Convector's License Law for the
following mason,(Section'703L5, Business and Professions Code: An,at mcounry
T' EMP, METER OR POLE INST,
which requires a Permit to convect, after, improve, demolish, or =pair any structure
prior to it issuance, also requires the applicant forsuch Permit o file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter
VALUATION
9(commencing with Section 7000) of Division 3 of the Businnssund Professions Code) SWIMMING POOL ELECTRIC
or that he is exempt thctefrom and the basis for the at legal exemption. Any violation of
Section 7031.5 by aay applicwt for a permit subjects the applicant ro a civil pcnolry of
OUTLL•TS-SWITCHI35-FIXTURES
��
t com than live hundred dollars ($500).
NEWRESIDENTIALELECfR_SQ, FI'.
STORIES
TYPECONSTRUCTION
ns
as ownerof the property, or my employees with wages as their solecompeation
is dm the work, end the structure is not intended or offered for sale (Sm. 7094. Business
Professions Code: The Cannaetols License Law does not apply to an owner of
property vehobuildsorimproves thereonand whodscssach work hlmselforthrough his
OCC. GROUP
RES. UNITS
for sale.If,
employ«s,provided that such improvementsu= not intendedonpleti
however, the r improvement is hath within one year of completion, the owner-
n.
TOTAL:
builder will hew the burden of proving that he did not build or improve for purpose of
have the b
ante.). n
[1 1, I, rof the property,am exdusivelycam=cling with licensedwnveaon to
QTY. PLUMBING PERMIT
FEE
FLOOD ZONE
APN
consuua the project (Sec, Lkq Business and Professions Code:) The Convedme
License Law does mum,ly to onowoerofprope cy who buildorimproves thereon,and
PERMIT ISSUANCE
who convectsforsuch projects with somwector(s) licensing! pursuanuothe Cmuuc=rs
AI TER - DRAIN&VENT - WATER (PA)
FEE SUMMARY
License
se Law.
❑ l am exempt undo Sec. . B & P C for Nis reason
BACK FLOW PROTECT, DEVICE
OUTS( E
SANITARY Y N_
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
DNAINS- FLOORROOFAREACOND.
.,,
SCHOOLTAX Y N
JD I hereby offirm that l have a cenificate ofconsenno self -insure. or a cenificme of
FIXTURE$ - PER TRAP
RECEIPT#
PARK FEE Y N
If
Workers' Compensation Insurance oro certified copy thercof(Sce. 3800, Lab C.) which
cOmo; all employee's ad&, this permit.RECEIPT
Policy M
GAS - CA. SYSTEM. INCA CUTLER $
BUILDING DIVISION FEES
Company
GAS - RA. SYSTEM.OVCR 4 (EA)
PLANCIIECK FEE
❑ Cmifted copy is hereby famished.
GRADING FEE
❑ CroifteA copy is filed with the city inspection division. GRFASEANDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be completed ifahe permit is forms hundred dollars($100) SEWER - SANITARY - STORM EA. 2001T.
or leaf
I certify that in me perfonwnce ofthe work for which this Permit is issued, l shall WATER HEATER W/VENT/ELECfR
not employ any parson in any manner so is in become subject to the Workers'
PAID
Compeneationlawsof Califomia Date
WATER SYSTEMfMEATING
hate Receipt#
Applicant -
TOTAL:
NOTICETOAPPLICANT:ILafter making this Certificate of Exemption, youshould NEW RESIDEMHAL PLMB. SQ. FP.
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed tevoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency fer the prumm once Of
TOTAL:
ELECTRIC FEC
rm
the work for which this Permit is issued! 3097, Civ. CJ
PLUMBING EEE
finders Name • *.'
Lenders Address QTY. - MECHANICAL PERMIT
IZE17
1 ccnify Net 1 have read this application and store that the about information is
"''
ssiggs'MECHANICAL
FEE
met. l agree to comply with all city and county ordinances and sta=laws relating to
PERMIT ISSUANCE
CONSTRUCTION TAX
building construction, and hereby authorize representatives ofthis city to enter upon the
shme-sono oed prnpeny for inspersion purposes.
AI:fCR OR ADD TO MECH.
We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmcnts, costs odd expenses which may inany way amnia against said City
AIR I IANDLING UNIT CFO 10,000 CFM)
in conseque of the gmntin f this per=il.
AIR HANDLING UNIT (OVER 10,00101217M)
Sigoaw=of�a V tDa=
EXHAUSTHOOD(W/DUCI)
PAID
II A RDOUS MATERIALS DISCLOSURE
1 ` HEATING UNIT (TO 100,000) BTU)
#
Date Receipt#
TOTAL:
Will the applicant or future building Occupant store or handle hazardous material HEATING UNIT (OVER 1110,1100 B1V)
as defined by the Cupcnino Municipal Code, Chapter 9.12, and the Health and Safety
Code, See.. 255320)7
❑ Yes ❑ No
VENTILATION BAN (SINGLE RESID)
ISSUANCE DATE
Will theapplicant orfuturebuilJingoc<upant useequipmentnrdeviceswbi<hemit
BOILER- COMP (311P OR IM,000 BTU)
hazardous air conuunmantx as define) by the Bay Area.Air Quality Management
BOILER-COMP(OVER 100,1100 RTU)
p�
P AID
slrict7
• ❑ Yes ❑ No -
NEW RESIDENTIAL MECH.—SQ. FT.
DECI1
1 have read the hazardous materials requirements under Chapter &95 of the
1A
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
u`
ifthe building does not cumn0y have. renank that it is my responsibility to notify the
�'� i tai'
Occupant of the requlremerm which must be mel prior to issuance Of a Certificate of
cur [I ,
Occupancy.
ISSUED BY:
Ownerthorized agent Dam T
=au
0—
OFFICE