24514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
(.,TTY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /� a� r
APPLICATION/PERMIT PLUMBING-MECHANIC.IL 2/1 ^ 1 A
BUILDING DIVISION BUILDING PROJECT'IDF,NTIFICA"r10N LTV 1 'T
pullAD���� DQMIT'a LOT'a SANITARY NO. A�;C=TIO�MIITA
UDATE
OWNE SN PFiO» C ACfOR:S NAME: LICN
-- D(LCa 7 S 17 i'f Q R J I 8s89 NIC CONTROL.N
• ARCIIIIE 7EJCINEER: LIC NO: DDRES
%4S 2i7`
7 v_w4s7b-, El
CONTACT: PHONE:
QPLUMTY. ELECTRIC PERMIT FEE BUILDING PG INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hemb Mon thatlamlicensnl under fChnt 9 gui TOR DESCRIPTION
W Ya Prov roes o per and
my Been ill
uF- O Moue andvfiDIVlSlon3of the 0usincss and Professions Cod<,and mylicense is in PANELS
K ccrnll cC1,c, cct. seyeg J
FZ hiccns CWss�Lica UP TO 200 AMPS
m Q Date nt
Cnmcmr 201-1000 AMPS w
ZON' ARCHITECTS DECLARATION OVER IOW AMT'S SQ.FE FLOOR AREA 1/SQ.I
OZ—❑ l understand my plans shall be used as public records.
SIGNS[LELTRICAI. n
QY�„� Licensed Prefccsion.l
W OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. '
Xla. 1 hereby affirm but 1 am exempt final the Contractor's License Law herdic g p EY
�LL�m following rtssoa(Section]07 L3,Business and Professions Cade:Any dtyorcoanty TAMP.METER OR POLE INS]. Nil II�JII a
N which requirts a perms to construct ager.improve,demolish,or repair any cracmm
�W> prior to its issuance,also requires the applicant for such piano to file a signed statement POWER DEVICES ✓1/Y
,=<0 That he is licensed Fummen tithe provisinnsof the Cnntmctor..License Law(Chapl,, r ,"I
a Xp�- 9(commencing with Section)000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VAI
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of 1
Section]031.5 by anyapplic-1 for.Pennit subjects the applicant m u civil penalty of OUTLETS-SWIT'C1ILS-FIXTURES
1 111/ �d..��
�+`•O not mote than five hundred dollars($500). +
❑ I,muwnerofthc progeny,ormycmployeeswilhwagesastheirsolecompcasation, NEW RESIDENTIAL ELECfR SQ.FT. STORIES 'TYPE CONSTRUC I'ION
y3_ will do the work,and OcmmGme is not intended mothered forsale(Sec.9UG4,Business
and Professions Code:The Commerce,License Law docs not apply to an owner of
property who builds or improves them amaisehodeessuchwork himselforthrough his
own employees,provided ilial such improvementsart not imendedoroffered flows.If, OCC.GROUP RES.UNITS
howeveq the building or improvement Ls cold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did matt build or improve far purpose of
ulcJ. CE1Y, PLUMBING PERMIT FEE FLOOD ZONE APN
construLicense the pmjat(Sec.oano Business and professions Code)The Contract,,,,,and
LicenseLaw does nmapply toanowacontrropeny who
sed pursuant
to
hontracand PERMIT ISSUANCE
Lho icense es.fors'uch pmjectswilhucuntrucler(s)liansedpumuanun the Contractors ALTER FEE SUMMARY
License law. (EA)
❑ 1 sm exempt under See ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEIS
SANITARY Y N
Owner Date• DRAINS-F1.00R,ROOF, GONDRECI?IPTp c WORKMAN COMPENSATION DECLARATION , , . SCHOOLTAX YN
❑ Hiereby affirm that l have a aniticate ifcmnmm he seins
lf- uoratt
re, rtifica4of FIXTURES-PER TRAP RITC121M#
m'Compen.munn
WorkeInsurance nr a ceni0ed copy thereof(Set.3800,Lam C.)which PARK FAIT Y N
all employee's under this permit RECEIPT a
GAS- SYSTEM-1 INC.4 OUTLETS
P°]")tinyy N 13A. BUILDING DIVISION FEES
Company GAS-E.SYSTEM-OVER 4(FLA) PIANCHECK FEE
❑ Cerified copy is hereby famished.
❑ CenifiW copy is filed with Ne city inspection division. OREASMNDUSTRL WASTE IN'I'ERCEPfOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectior need nut be completed ifthe permit is fact handled dollars(SIW) SEWER-SANITARY-STORM F.A.200 T, ENERGY FEE
ode's.)
I cenify that in the pcomuclocifthe work far Which his pernit is issued,)shall WATER HEATER W[VEN'f/ELECTR
not employ any person in any manner
r.r as to become subject to the Workers' PAID
z Con,marivon Lar—of Califomia. DineWATER SYSTEEV RFATING Applicant Date ReceiptN
zNOTICE T'O APPLICANT:If,after making this Cemficateof Exemption,yetidould NEW RESIDENTIAL MAIL SQ.IT. TOTAL:F' become 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 _N
0. CONSTRUCT]ON LENDING AGENCY SEISMIC FEE
ZD Z 1 hcreby.ffirn thin The,.is.lomarumion Icnding agency for the performance of
V C) the work for which this permit is issued(Sec.3097,Civ.C) TOTAL: ELECTRIC FEE
Iw:nder',Name
CU Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is
comect.Iagree to comply with all city and county eminences and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
I-" C/) building construction.and hereby authorize represemmivesidthis city toentefupen the
U Z .hove-mentioned property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agrea to save,indemnify and keep hornless the City of Cupertino against
habiliims.jul setas casts�d expcneeswhich may in my wayaccom against said City AIR HANDLING UNIT(TO 10,1100 CFM)
consequen off ge. ,sefthis pelma.
U AIR HANDLING UNIT(OVER 10,000 CPM)
go wmnf Apl 11 a t/C racurr Date EXHAUST HOOD(W/DUCD
PAID
A DO fATER1AIS DISCLOSURE HEATING UNIT TO IW,W1)BTU) Uat< ReceiptN
Will the apPlicum or fmureb dingoccupontxtomofhendleh.dousmateriol
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEA TING UNIT(OVER 100,000 BTU) TO
Code,See ..23532(a)?
❑Yes ❑No VEN'T'ILATION FAN(SINGLE RESIDE
BOILER-COMP I$$UANCIi DA
Will tail co ieraniments as building by thenmm Area it Quality Management
(3HP OR 100,01q BTU)
• harerJt? Lir conwminmts az defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100.000BTU) P
DistrictR
❑Yes ❑No ENEWRMIDE�IALMECH. SQ.ET
I have read the harrardous materials requirements under Chapter 695 of the NOV 24 100
California Heahh&Safely Code,Sections 25505,25533 and 25534. 1 and... adthat
if the building dos norclammily have summer,that it is my responsibility m notify the
mccapam of the requirements which must Is,met prior to issuance of a Cenifcate of CITY ur (,'Jrrn 1
Occupancy. 1 y
Owner or amhonmd agent Dam
'TOTAL: ISSUED BY:
OFFICE