24489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL. /�� II
BUIL DING DIVISION BUIDINGPHMKCI'IDENTIFICATION L 4l8J UVJ
ILDING ADDRESS:en — 1� j ��yp"� SANITARY NO. APIIJCATIONwwwS���UBmrrI�]IAAI..DATE
&U. /V UNIT# LOT if
O jIME:. &1,7w PHONE: N'ItnCTOR'S �� /}7 IC NO: N/C CON I'ROL# 'v
o
ARCHITLCI'/: WEER: LIC NO: DRE 1 '1 �u ///�/ / �
COSTA A 5 PHONE. QTY. V ELECTRIC PERMIT ('�•I/ FEE v`I BUILDING PERMIT INFO
BLD I..[,E,Cf 'CLUMV ME❑CH
PERMIT ISSUANCE, El El N94
LICENSED CONTRACTOR'S DF.CLARAI'ION APPLIANCES-BESIDESTIAL
Fneelz100 Thereby afirmrhm L3 ofth licensed provisionsof Chuode said my wence,with JO ON
-W— Section 90001 of Division3nf the Rosiness and Profession Code.and my licenu is in PANELS
yUu full force and,ffect.
<,,2 License Class Lic.a UP TO 201I AMPS `
myDate Contractor—
= 201-1000 AMPS ,u
Z to DECLARATION OVER 10011 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
1 undersand my plans shall be used as publi<records.
SIGNS ELECTRICAL
LTnen.ed rrtfesaional
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. ff�'�-.Nz p
XCaU I hereby affirm that 1 am exempt from the CtnPeam'a License Law for the tl `k.J' T E
m3Qy fellowingrcasov.(Section70315,BusinessandProfessionsCode:Anycityorcounty TEMP.Mli1'IiRORPOLEINST. f�l
F"uJ y; which requires a permit In amstruch:atet improve,demolish,or repair any stmcturc
5'uu1117 prior its issuance,also requires the applicant mrsuch permit file a signed statement POWER DEVICES
V=C<O that he is licensed pursuant to the provision of the Contributes License Law(Chapter DATE
t•da 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cale) SWIMMING POOL ELECTRIC -
k,.,1'• VALUA'I'10
,,may nnhat he is,aempnhercl'mnumdthe fasts farthcalleged exemption.Any,mlancrof FIXIIIRES
FZQ Section 7031.5 by any applicant for a permit subjects the applicants a civil penalty of OUTLETS-SWITCHES-
�� not mare Nan five hundred dollars(5500).
_� NEWRESIDENTIALELECIR S FT.
o ❑ Lasownerofthepmpcny.ormyemplsyttswith wagesas theirsolecompensation. Q STORIES TYPO CONSTRUCTION
I
willdo Nu work,and thearubmre isnot inTcnded aottcred fnrsale(SwA(W4,Business
and Professions Cede:The Contractor's Littnse Law does not apply m an owner of
property who builds cr improves Merton,and who dses such work himself or through his
employees,provided that such improvemenaare not intendedoroffercd forsale.If, OCC.GROUP RES.UNITS
however,the huilding tar improvement i.v nold within one year ofcnmpletion,the owner
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
C3 I,asowner- WOOD QTY' PLUMBING PERMIT FEE F100D LONE
APN
Ilse, the does act
Sce,apply
9044.Business and Professions Code)The Continuous and
Littnse Lawton not Project with acrofpropeny whobdpurn lm to the thereon,and PERMIT ISSUANCE
who ro Law,for such projecuwiNacomtacmt(s)Iittnsed pursuanuotM Contanor's ALTER-DRAIN&VFNT-
Lmbnse Law, WATER(EA) FEE SUMMARY
❑ I um exenpt under Scc. B&P C Ern this rcasamOUTSIDIi FEES
Owner
BACK FLOW PROTECT'.DEVICE
SANITARY Y N
mDRAINS-FLOOR,ROOF,AREA,COND. RECEIFTN
WORKMAN COMPENSATION DECLARRATT ION
❑ SCHOOLI'AX YN
Thereby aflinn rhatlhaveacenificme of nm,ent to Self-insure,ora cenificam of FIXTURES-PER TRAP RECEIPT'#
Wtahers Cnlnsoaneenrzocnified copy thereof(Sec.3B00.Lab C.7which PARK ME Y N'_
oven all employee mployee'vs under this pemTit.
Policy X GAS-EA.SYSTEM-I INC.4 OUTLETS R[CEIPI'X
Company BUILDING DIVISION ETES
❑ Ccnifiedcapyia hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEpNDUSMJL WASTE INIF.RCEPMR GRADING FEE
CERTIFICATE OF EXFMPLON FROM WORKERSGREASE IRAI' SOILS EGL'
COMPENSATION INSURANCE
('Thissecfinn neednot becompleted ifthepermitisforonehundm dollar(SIM) SEWER- NITARY-STORM EA.200FT.
or Icss) ENERGY ITE
I ttnify thm in the performance ofthe work far which this permit isicsued,Ishell WATER MATER WNENT/ELECI'R
not employ any person in any manner so as to become subject to the Worker' PAID
Q
z Cnmpbmarom laws of Califomins. Dam BE
WATER SYSI EMOA'I'ING
Applicant Date Receipt X
z NOTICE TO APPLICANT:IL afmr making this Cenificateof Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT.
V] become subject to The Workers Compensation provisions of the Labor Code,you must 'TOTAL:
a 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE _
0. CONSTRUCTION LENDING AGENCY SEISMIC PEE
Z I hereby affirm that there is a wnstructitn lending agency for the performance of
V O the work for which this pemti T is issued(Sec.306].Civ.CJ TELECTRIC FEE
Lender's Name
OU lenders Address QTY. MECHANICAL PERMIT IEE PLUMBING FEE
1 certify thin I have read this aprLcannn and one her file above infammhon is
FRW. mnect. l agree it)comply with all city and county ordinances andstare laws relming to PERMIT ISSUANCE MECHANICAL FEE
N buildingconsrrvction,and hereby authom<repreanativesofoischy in enter upon the
U z above-mentioned property far inspection purposes ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree ro save,indcmnify and keep harmless The City of Cupertino agulast
liabilibies,rydgmmms,cows an xpenss which,.irray in way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
o •yuena of the tai this pcnnT
r
AIR HANDLING UNIT(OVER 10."CFM)
Signet reof ApplicanUContmnnr Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Date ReceiplX
Will the applicant or future lonlding,wcupanr.afire or handle hazardous maerial
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IN ON)BTU) T L:
Cade.Section 25532(a)]
❑Yes 11 No VENTIfAT10N FAN(SINGLE RESID)
Will rheapplicunmrfulumbuildingoceuputuweyuipmemtrdeviceswhichemlt BOILER-COUP(3HP OR Ilk,"BTU) ISSUANCE
y DATE
Ward...air contaminants as defined by the Bay Area Air Quality Management BOILER 0
Disvin) COMP IOO.000 BTU) NOVQ nn
❑YLbtilding
s ❑Nn NEW RESIDENT IAL MSCI I. SQ.FT. N 3 190
ad the hazardous materials reyuiremems under Chapter 6.95 of the V
California
lth&Safety Code,Sections 25505,25533 and 25534. I undersand than
n an
if ly With amount..Prior my resanniof. room]lythe CITY Err Curr-
rcquircmena which moa M:mu prior¢,issuuna of a Cenifmme of V V nzed agent Dam TOTAL: ISSUEDBY: Vim/
OFFICE