24784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. w
APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: /� SANITARY NO. APPLICATIONSUBMITTALDATI
•� G-Tol+o UNIT# I.OT# 212
litia
OWN, SNAMIi: p,PHONE: CONT'RACTOR'S NAME: LIC NO:
I I ZS NIC CON IROLOf
.RCI IITECT/1' GINEER: LIC NO: AUD 'SS:
er 55 - �HCl�� fj✓� SJ ❑
CONTACT': PHON :/.y 08) BUILDING PERMITINFO
QTY. ELECTRIC PERMIT FEE
Ih4 2qW—�Z PERMIT ISSUANCE BLDG ELECT PLUMB MECH
❑ ❑ ElLI 'NSIiD CONTRACTORS DECLARATION APPLIANCESRESIDENTIALJOB DESCRIPTION
EJ02 Thereby Division
3 ofth Business
and ossesions Codr add mmendng with
�sf00 fall
orceand of Division Sof the Business and Profcssio Cods,and my license is in PANELS
14Wfull force and effect 4q ZUZ UPT021XIAMPS
F-L W License Clava 1.1C,X V
mayData .Cnnvanor 201-IOW AMPS
7OyZ ARCHITECTS DEC TION OVER 1000 AMPS SQ.IT.FLOOR AR EA S/SQ,FT.
]understand planashalbe us ed bl' onal
F:OnF' SIGNS F:LECIItICAI.
C6' 1_i I.icensmP e, onal
CC< WNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOyF 1 hereby off t Nat 1 am exempt from the Contractors License Law for the
{a]3ay follewingreaenn(Section 003[.5,Business and Professions Cale:Any city orcmaa, TEMP.METEROR POLE INS']'.
FLLon j which requires a permit to covaVuc6 alter,improve,demolish,in repair any structure
CWQM final to its issuance,ads.requires theapplicant murder permiuo file.signal statement POWER DEVICES
m K O that he is licensed pursuant to the provisions of the CouO.noes License Law(Chapter
aaoW,, 9(commencingwltb Scdinn]0)(Bof Divisma2l orthe Bushossand professions Code) SWIMMING POOL ELECTRIC VALUATION
x orthat he isexem t thcrefromand the basis fortheallc edenem t yvio
u1—m P g Piun. civil
Inion of
FZQ Section than by five
hundred
collars apermit subjects the applicanuoa<ivil penally of OUTLETS-SWITCHES-FlXTURES
W'O not more then five hunJred dollars($SW).
�� ❑ I,usownemUMpnrlwny,onnyempinyecswlN wagesas thcirsolcuvnpsnsmion, NEW RESIDF.NTIALIiLECI'R _SQ.Ff. STORIES X.TYPE CONSTRUCTION
a3— will do the work,and the structure is not intended oruffined for sale(Sec.70,W.Business
and professions Code:The Contractor's License Law dos not apply to an owner of
property whubuildsor improves therenn,th d whodoessuch work himselforthrough his
on employees,pvidcd shut such iinpmvenundare nett me kdorurfcud fit GR
rsale.If, OCC OUP RES.UNITS
hom
waver.the building or improvement is sold within one yammt completion,the owner.
builder will have the burden of proving that he did not builder improve fiapturRosseft TOTAL:
sale.).
❑ I,as ownerofthe property,ton exclusivelyanmacting with licenmd mntmaors G PL I PER I FEE FLOODZONB APN
ntxouct the project(Sea 7004,Business and Professions Code:)the Contract s
LicenseL wdosnotaWlytomownerufpropenywhobuildsor impeav,sthereen. 1 UA
whoconmacts for such projects with a conuanor(s)licensed pursuant mine Contractor's
License Law. LT,.R qRW&I fi - ER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for th1's rezerm
BA JI SANITARY OUTSIDE FEES N_
,4007
wrur Dam
WORKMAN COMPENSATION DF.CLARADON DRAINS-POOR,ROOF,AN EA,COND. RECEIIsI'X
SCHOOLTAX Y__N
❑ ce,'Coyuffirmthatlhaveacora scam of copyfmam rondf(Scmre,er Lab C.)c which
FIXTURES PER.TRAP RECEIPfp
wnrkers'Compenwtion lnsumnceeracertified ropy thereof(Sec.3800,Lab C.)which PARKF-EE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'p
Policy X
Company BUILDING DIVISION FEES
(EA)❑ CenGAS-EA.SYSIEM-OVER4 f
ifeJ copy is hereby famished. PLANCHF.CK PER 1
❑ Candied copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
C17RTIFICA'I E OF EXEMPTION FROM WORKERSGREASEIRAP SOILS FEE
COMPENSATION INSURANCE
(this-cin-used act be completed ifthe per mit is Fatigue hundred doll.(SIM) SEWER-SANITARY-STORM EA.2WFT. ENF,RGYIEE
m las..)
I certify ihm in the ficrrnrmance of the work rnrwhich chis permit is issued.)shallMSYSTEMfrR�nNG
iYf/ELECTR
not employ any person in any manna,so u m become subject m the Worker.' PAID
z Compensmion hws of C.lifomia. Data TING
Q Applicant Data RueiptX
Z C) NO TICE TO APPLICAN'r:ll.after making this Certificate of Esemfitom,you shouldMB. SQ.FT. TOTAL:
V) becamesabact ie the Worker's Compensation provisions of the Uber Cade,you must� foMwith comply with such provisions orthis permit shall be deemed revoked. BUILDING FEE
pal, Q CONSTRUCTION LENDING AGENCYSEISMIC FEE
Z I hereby affirm thatthen is a construction lending agency for the performance of
O the work for which this pemrf,is issued(See.309].Civ.C.) TOTAL: ELECTRIC FEF.Lenders Name
C) ULenders Addmns QY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have react this application and state that the above inromution is
FG correct. l agree mcomp)y with all city do ty cardinanc.fand sure laws mlatingm PERMIT ISSUANCE MECHANICAL FEE
rn building construction,and herebyuu rite represenmriva,.f
thiseltymenmruponthe
U Z abnvc-mentioned progeny for conn purpnus. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,in nify and keep harm itof Cuertino
y pagainst
.. Imbilities,judgments.ro Jexprnus which y accrveagaotsaid City AIR HANDLING UNIT(TO I(t0IX1 CFM)
a.roI
nuqac
uee nfth ting of this permit.
Z 2L Q7 AIR HANDLING UNIT(OVER 10.000CFM)
A '/7
Sigwmre ofA filicant/ tractor Date EXHAUST IIOOD(W/DUCT)
PAID
AZARUOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0MBTU) Dae Rec_i,a
Will the ap,lic.m or future building occupant smrt m handle madedous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I IEATING UNIT(OVER I WWRMDF�IALMECII.—SQ,
W BIT) TOIAL
Code,Section 25532(a)Y
❑Yes 11 Nit VENTILATION FAN(SINGLE RPSID)
Will Neapplicamorfuurebuildingoccupantuu cqulpmentordevices whichemit OR 100.000 BTU) ISSUANCE DATE
tiezvdous air contaminants as defined by the Bay Area Air Quality Management
Inouicf! COMP 100,000 BTU) PAID❑Yes ❑No MECH. SQ.Pf. AI have read the harofety Co e,materials requirements under 34, 1 ur erst of theCate buil ing lthdo&of cur Calc.Scaave a sec25505,t it is and 25534. 1 ity to n of theifthebutWingdosnotcurrentlyhaveatennt,etois myrespnceoila i notify theC
occupant of the reyuiremenu which must h met poor to issuance of a Cenifi<ae of
Occupancy. _ V/'
Owner ar amhonzed.gem Data vim/sv%/)�I�=).
TOTAL: ISSUED BY:
OFFICE