24671 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO /� C7
H.DING-ELECTRI AL PIiRMI'1'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ^ 1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION' G 4 v r
BUIL Di G DDR S:1 p I Gµ T Ido
SANITARY NO. AP1PLICATION SUI3MITTN,DATIi
/ERR'S7NAME:
�r0, I�Iu�TTI�„J J� G PHONE
IVGJ CONN N LGT# Y�l%A�
�OWNSW61i/V - I &H ND as-z—J1CONTRACTOR'S NAMB: 0 LIC NO: NOU CONTROLp
AMC]111 LCI'JENGINEERt LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI]
PERMITISSUANCE El ❑ 0
LICENSED CONTRACTOR'SDECLARATION gppl.lANC55-RESIDI3NTIAL JOB OF H"HON
Oyez IM17001 ofimuhnl[3 ofthnsedinss and klonsres.Cod,and
(commencing with in
WOO Section 7alU)of Division 3of the Business and Professions Cale.and mylicrnse is in PANELS
Fa'.0 full force and eRna. Vim/
ZW License Class Lie# UPT02WAMPS
an?N Date Contractor 201-IOW AMPS
z0 on K, ARC]III EC'S DECLARATION OVER]"AMPS
understand my
SQ.FT.FLOOR AREA $lSQ.IT.
O z—0 1 plans shall be,used as public Imunds.
F E'; SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
j<O c". 1 hereby M.that, 1 am exempt from lbc Conlracmf's Licensc Law fur te
h
n1''u.r¢r following reason.(Section 7031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INSI'.
F�' J which requires a permit to construct,a ieq improve,demolish,or repair any swemrc
.E'uW�of
1'YS prior m its issuance,also requires the applicant for such permitto li le a signed statement POWER DEVICES
WK 0Othat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
dkomLL 9(connumming with Section 7")of Division 3 m ine Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—y or that he is exempttherefrom and the basis for the alleged exemption.Any violation of
tz,T Section 7031.5 by any applicant for a pemtit subjects the applicant o a civil Penalty of OUTLETS-SWITCHES-FIXTURES
Sap at more than five hundred colla,'(5500). `
ycmp y g pcnsadon, NEW RESIDENTIALELECIR IT.
W E-o ,asownerofthepropcny.orm to mswithwa esastheirmlecom —SQ. STORY® PE CONSTRUCDON
c. ill the work,and the smarture isnot intended croffned forsale(Set.7094,Business rl!C>—moo
and 1'rotessions Cale:The Contractor's Licensc Law does not apply to an owner of ��
Property whobuildsorlmpmves therwn,and whodoessuch work himselforthrough his
own employ.,,provided thm such improvements are not inicndedoroffcred bnsale.If. it n ( G lU RES.UNI'I'S
however,the buildingor improvement is sold within one yearofcompinion,the owner-
builder will have the burden of hal he did not build or int purpose n TOTAL' V#
provingt prove for f
sale.,. QTY. PLUMBING PERMIT / 1'N
❑ Las ow pr ject(Sec.7 , eacWsis and mmctsions odc.)Tdcommerorsrs T
<onswm 0a project(Stu.9044,Business end Professions Code:?The Contractors
License WwaPPlymanowncenywhoorimpro thereon,and
PERMIT ISSUANCE
whocon0acs for such Projects withecommucaorts)licensed pursuwuothe _
Convenors ALTER-DRAIN&VENT-WAI ER(EA)
Licensc Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA.GOND. RECEIPT#
WORKMAN COMPENSATIONraleofDECL9RATION SCHOOLI'AX Y N_
❑ in,'CiHaerebyaffiam that hamate have a eAficarcof eopythen.f(insvrc,orad,C.) which FIXTURES-PER TRAP RECEIPT#
Workers Compensation Imamate earracenifed copy Nereof(Sec.38W.Lab C.)which PARK FEE Y N
covers all employee's under This permit. GAS-EA.SYSTEM-1 INC.4 ON LETS RECEIPT#
Policy# BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER 4(F.A) PLANCHECK FEE
❑ Certified copy is M1ereby famished. _
❑ Cenlfied copy is riled with the city inspection division. GREASFANDUSTRL WASTE INTERCHPFOR GRADING FF.F.
CERT IFICA'I'E OF EXEMPTION FROM WORKRRS' CREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseelion need not be completed ifthepermil is for one hundred d.1fies E$IBM) SEW13R-SANITARY-STORM EA.2001T.
or less) ENERGY FEL
I certify that in the Immoremardf@e work for whichthix permit is issued,Ishdl WATER HEATER W/VENTIELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Z Compensation Laws of Calimmia. Date WATER SYSTEM/IREATING Date ReceiplN
Applicant
Q O NOT ICE TO APPLICANT:If,after makin8 this Certificate of Exemption,you should NEW RESIDE AL PLMB. SQ.FT.
P (q becomesubject subjeco the Worker's Compensation provisions ofthe labor Code,you must TOTAL:
fonbwith comply with such provisions or this permit shall he deennedovoked. BUILDING FEE
gCONSTRUCTION LENDING AGENCY SEISMIC FM
Z) 2 I amhy afrirrn thin there is a constriction]coding agency for the performance of
V O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
lenders Name
ULeaders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and stare that the amat
above information is
F a cunect.Iagrc<to comply with all city and county oNinanasand state lows relining to PERM1'1'ISSUANCE MECHANICAL FEE
V) building construction,and hereby authorize representatives ofth,scity,to enter upon the
U Z above-mentioned property for inspection pugroee, ALTER OR ADD TO MECI I. CONNOR UCr1ON TAX
(We)agree to save,indemnify:tad keep hurdles,@e City of Cupedino against
rabllitica,ridgmcnu.casts and expenses which may in any way accme agaimI.id City AIR HANDLING UNIT TO I Qo011 CFM)
in consryuence,f the emotingof this Pc it.
_ AIR HANDLING UNIT(OVER M."CEM)
ra
nature of Applies numel ,D`ole IiXHAU$T HOOD(WNUCI}
PAID
H ZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant of firms building occupant score or handle humorous material
asdefined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) p
Code,Section 255321a)Y
11 Yes 0N VENTILATION FAN(SINGLE RESID)
Will IM1cupplicam or futurchuildingoccupanmseeyuipment or Devices whichemit
BOILER-COMP(31 IF OR 100,000 8.1 U) ISSUANCE DATE
gift harci air cnntancs as dBOILER.COMP efined by the Bay Area Air Quality Management
' "He
mina (OVER 109,000 BTU) f.�
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. p Q tlr' V
I have read'he hazardous materials o ulremcnas under Chapter 6.95 of the � Z
CnlCaliforniaHcahM1&Safety Cede,Sections 25505,2553]and 25534. 1undcmJAN -(
and,hot ry '(
if the building does not currently have a tenant,that it is my responsibility m notiEstee /99'?
awcupanl of she term Ioenrems which must be me nr to issuance of o Certificate of/
cepancy. ^//w�AIY�. —/L� } �•ITY Uh C(IroF,r
owner m mrh coed aged Dae
TOTAL: ISSUED BY:
OFFICE