24726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE SALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITN°' 2 4 7 2 6
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDE\TIFICATION
P.UU,DING ADDRESS: SANITARY NO. APR-C
ATION
SUBMJTTAL DATE.
Ovt- UNIT# LOI'0
OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO.
A� �� If N IJ NC CGNTRGL#
MITEC'DENGINEER: LIC NO: ADDR N S:
i� - of o et _ El ��ti'
CONTACT: PHONE:
J O QTY. ELECTRIC PIT EEE BUILDING PERMIT INFO
PERMIT ISSUANCE
LDG ELE PLU ME
LICENSED CONTRACT'OR'S DECLARATION APPLIAN -R DENTIAL JOB DFS ON
p0Z Ih7")ofDiision 3 afthe uMuhrpm PriannofsCode9nd my lcepg wmiM1 �tr� �tt�
[+100 Sca ion9UUldefect.Division the Businm and Profwims Code,and my Ba"a,it in pANELg t 1 � D�
m mu roree and CBCCI.
O Lice's Clnsr L,# UP T I AMPS
V~j'l y Gone Commacttt
E- AMPS
ONZ ARCHITECTS Is,used
His A'DON 1000 AA1PS SQ.FT FLOOR AREA S/SQ,FT.
OZ^� lunh'innd my pions eM1ell he uscdupubllc tttvmrtL.
Fy \ IGNS EL A 100 3�
� Lied Pnafecri� v ���""IVVI GrI
f¢��6 OWNLR-BUILDFR DECLARATION SPECIA 1 U ISC. y
�'OycU. 1 hemby u(rrm Thal l inn exempt from Ne Convenors Lirsnx I-w(- the _+
r 3u-v. followingreason.(Sectiun 90315.Business and Prof,lou Code:Any city or county TEMP,ME OR PULL INST.
which acquires a mnit In mashun,alar,improve,denwlish,a repair nary structure
t >� piorloim isseance,also requires lM:applicant f«wct permon,flea signed samear m POWER DEVICES
(y�j^Qp mbar he is lrommal purumn mthe povui«uofrne Comranor'v Licersu Law(Cnepter
mm 9(cmmencingwith.altml000)ofdvlsl 3oflhc Burinm%mrd Professions CoJx) SWIMMING POOL ELECTRIC VALUATION
or hat he is csemptM1crefrom and lhchuis for 0w ellegal cxempinn.AnyviMuionof UTLETS SWITCHES-FIXTURES �� ��
�Z< no,mn]0rmfi, mydroad dollars($50(f.
wbjecls IM1e applicant loucivil pcls' of
02 no,more then fve M1urdmd dollar'(5300). NEW RESIDE1,MAL ELECIRS .F
z�zm ❑ Lm'owrcrofthe property,ormyarnpuyecswilM1 wegesulheirsnlecomperssuimr, QT. STORIMI TYEFCONSTRUCTION
per, will do 11 be wnrk,andlre slrunmeismanuendeJ«ulTered for Wn(Sa.)044,Buxircas
and Prefossions Calc:no Contractor's Licermc Law does nos apply to an me.of
pmpcvywhobuildsorimproves llRvnon,nnJ wM1odoexsuch work himulforthmugM1 If,
U R
rwr
sver.the building
uip�ng or improvement l eir wen impovcrmnthin met intended moffetW ey,mlc.If,
Ei Lr
M1olds,willhtvldhe Woofprosiswl he didnom build ofcomplefor thpose of
buiWcr will M1rvc the M1urden of posing IIYI he did not build ca improve f«purpuac of
PLUMBING PERMIT FEE N�
❑ Las owrvonite pnyenr.amexel�sivelyemtnning wmin 11«n.�a«.,tronm.lo Q
oprom uet the project(Sm.9014.Business and Profeolms Corn:)The Centmctore PERMIT ISSUANCE
Limnx Law drca'«apply to en'ware,of proprnY who builds m improves therron,andrc DATE
whOenrl Ira's f«such projeClx wiln aconlrxlor(q l2n]Ed punuenl m the CMVYYaf
Li«n+e mow. AL'Illt-Danw At vExr-WATER(en) FEE SUMMARY
❑ 1 am exempt under Sac. B&P C for Ilk regard BACK FLOW PROTECT.DEVICE SANITARY ° Y N
r DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
[3rRX�1myrf; WORKMAN COMPENSATION DECLARATION SCDOOLTAX Y N
Apsl Rarely orf mrlhetlhaveaccnificvc of canunuo sdf-insure,«vnnif tc of FIXTURES PER.IRAp RECEIPT#
adtraC«npmettion loumnce or a artif'l copy lhenaf(Ses.38OQ Lab C)which PARK FEE Y N
sevum(all empbyce's wdn IM1is permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RECF,I
FA
r PMlcyt BUILDING DIVISJIFEES
Company GAS-EA.SYSTEM-OVER 4(LA) PLANCHECK FEE
❑ Ccnificdcnpy,bersebyfumided.
❑ Ccnlfnd copy ie fled wish IM1c city Inspection division. GREASEINDUSTRL WASTE F EFERCEPTOR GRADING ME
CERTIFICATE.OF FXEMP`BON FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisecdion need not 4mmpead lfthe permit is fmronehundreddollsn(51(0) SEWER-SANITARY-STORM EA.200P1'. PNFRGYFUF �1
or I¢s)
Icrnify Nvt in Ne pmforrencc of IM1c work forwM1ich Wspcmtil uiuuM,l snail WATER HEATER W/VENT/ELECIR
not employ vary pva,an in my manner so rr to be»ine subjcd to the,Workers' P
Z CAonlpcnoaamnlswsof Cnllfcanor Date WATER SYSTEM/BEATING Dale Receipt
pP
z 0. NOTICE TO APPLICANT:If,after making this Canifroam of Exemption,you ahsvmkl NEW RESIDENTIAL PLMB. SQ.FP. TOTAL
,0 become runes,to IM1c Wodscr's Cwn,essmian provisional ofthl Laber Code,you must
forthwith comply with such previsions or Ibis parmit shall be damW mvmk d, BUILDING FEE O
Q CONSTRUCTION LENDING AGENCY SEISMICMba
1 h'eby affirm Thal there is a conduction lending agency for Be pMmmatre of
(� O
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lander s Nvric
1<rdcr's Address QTY. MECHANICAL PERMIT FEE PLUMBING FE
U I srrtify man 1 have used this application and awe that the above information is
0. mrrea l agree In comply with all city and county«dinures and store lawsmleting to PER ISSUANCE MECHANICAL E
Iconsorted.,and hcmbyamhods rcprrxnutivcs of IM1is citym cone,upon lir GGNSIRUCTIO TAX
U z above mcmimrd property forne,pocion yurp«-s ALTER OR ADD TO MECH.
(We)agree to sas,indemnify and kap harmlessthe City of Cu mw vg.a"
livbiliiigjmdgnsnq roes and experssa'wM1ieM1 rosy In my we yypeee 'ty AIR I IANDLING UNIT G70 10,"CFM)
nxquenceoftheg tingofihispnmil. / e
Tyra NR HANDLING UNIT(OVER 10,000 CFM1I)
wum of Applica nlm'or t, EXHAUST FOOD(W/DUCT) - PAID
HA RDOUS MATERIALS DISCLOSURE. HGTING UNIT(TO 100,M)BTU) Eats
Will the applicant orfunum building occupant store m handle hsserd«Is reatmel HEATING UNIT(OVER 100,000 BTU) pTAI,:
as dnfm'1 by the Cupmmm,Mimmeipd Gude,Chaplin 9.12,and IFe Health and Safety
Gude,Scalia'25532(e$
❑Yen El No VE THLATION FAN(SINGLE RPSID)
SSUA
Willtheepplicune"mutebuiWingoccupantusequipnrnt«devicss wM1iehenmil BOLLER-COMP(3HP OR Ifp,(IOD BTU)
Atdous arse conterminous as dcfned by IM1e Bay Area Air Quality Marmgcmenl BOBFR-COMP(OVER 100,IXlOBTU
'dlflell .
Cl Ya ❑No NCW RESIDENTIAL MF.CH. SQ.II'.
/ 1 Mvc road the"a",malarid5 maninemenn under Chepmr 6.95 or the
Califomm llcalih A,Saf'y,Carlo,Sections 25505,25533 and 2551pnl34. I understand that FEBif the building does not cuoupoly have a m ,that it a my rtapouiMlity to ratify IM1e `� �Q
occvpun or me reymrem,mm wmon ma.l <m'I�im to isaaatKe of a crnirc.te nr + �—. J
Occupancy. CITYILQ
ys C
n oars
Owner m amlwrixcd again Dam ISSUED BY:
OFFICE