24826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[BUILDING
TY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24826
BUILDING DIVISION BUILDING PROJEC,F IDENTIFICATION
ADDRESS: , 1SANITARY NO. APPLICATIONSUBMIALDATLa 1s4ts N RAIAIIS aA2UNIT n LOT#
NIiRS PHONE: CONTRACI'OR'SNAAME: LIC NO:
s IN 50N a.S�-9683 �• IS 1' lYl / � 8/ N/C CONTROL#
>RCf{ItiCryENGINF.fiR: LIC NO: ADDI ,SfhPX 36 2. o j.4 ❑
e ' ' 0 6
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
JDA C(0-60to PERMIT ISSUANCE BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL. R
Oy0 Ib 7000)of Do
L3 fine minas.rad Profession Cod r and mmendng with LOB DESCRIYI'ION
"W00 Nil irameadefDivisian7o[the Business and Professions Code,and my license is in PANELS
gym—�. ron came ma erceet .1� / f
¢Zo License Class ��3L L;Gp xI 81 UPT0200 AMPS -JAS 1/V2 '7p BOO K.7D�
vf—ijy Dem 3�.� / �Comtncror 201-1000 AMPS
ZOy4 ARC{IITIiCI'S DEp.ARA'1' N OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z to 0 1 understand my plans shall be used as public recoNs.
Pti Fw SIGNS ELECTRICAL
QY�❑ Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Ecc.
wu 1 hereby affirm that 1 am exempt from the Contractors License Law for the
ta1WOm following reason.(Section 7031.5,13aslnes and Professions Code:Any city or county I HMP.METER OR POLE INS1',
L'—ywhich reclaims perm;uo constrvm,alter,improve, repairve,demolish.or repair any strucstructureu
,WYM pnicoitsissuance,also requirestheam
pplict forsuch perad,to file.signed statement
POWER DEVICES
K O That he is Iicemea pursuant to the provisions of the Contractors License Law(Chapter it Fr
XMX 9(commencing with Section 700(1)of Division 3 ofthe Brounessand Professions Corte) SWIMMING POOL ELECTRIC I ice. �• � �yALUATION
el--m or that he is exempt therefrom and the cavil for alleged exemption.Anyviolationof CIA LETS -FIXTURES 0 _'
FZa Section l(131.5 by any applicant for a Petah subjeas the applicant to a civil penalty of r
^y 0 not mon than five hundred dollars($500).
LB�p— ❑ ud
NEW RFIDMIALELI _SQ.W � 1,usownerof0epropay,mmyanpleyeswihwugeswtheirsulecompmatim, bq
TYPECONSTRUCTION
willdothework.anathestrvctmismt;me^ cdoroffendfmsale(SiteA044,Business A
and Professions Code:The Contractor's License law docs not apply to an owner of
properly who builds or i mprovel thereon,and who docs such .,it hinamlror through his
ownemploces,providedthatsuchimpmvemencsamnotintendeaoroffcredforeale.If,
OCC GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
t).
❑ I,:uawneroftbe prhpmy,am exdusivdy n,ntraainswith GemwJcnmracuhrs nh QTY. PLUMBING PERMIT FEE Iq,OOD ZONE APN
construct the project(Sec.7044,Business and Professions Code#The Convectors
License Lawdees not apply manowncrofpropanywho builds mimpmvesthereonand PERMIT ISSUANCE l
wh icommets forsuch projects with accomp n ist licensed pursuant m the Contracmrs
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um cnempt under Scc. ,B&P C!m this rcnsmh BACK FLOW PROFGCT.DEVICE OUTSIDE F'IiES
SANITARY YN
Owner DowSANITARY
SCHOOLTAX Y DRAINS-FLOOR,ROOF,AREA,COND. RECEIFf#
WORKMAN COMPENSATION DECLAN
❑ Iherebyafil that l have.ceri0eme ofamucarto self-insure,or a cerfifcam of IXTURES-PER TRAP RECEIPT If
Wmkem'Compenuaion Insurance or a cenifed copy thercof(Sec.3g01),Lab C.)which PARK PGE Y N
coversall emp `cg m Icr his pc t. /
Beyr' Y I�IO� GAS-EA.SYSTEM-]INC.40I1TLETS RECBIPI'#
Company tsYAio.� ^aa,<ca al+a-C� BUILDING DIVISION FEES
❑ CeNBeni copy is hereby famished. GAS-EA.SYSTEM.OVER 4 UA) PLANCHECK FEE
Certife4 copy is flet with the city inspection division. GREASETNDUSIRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PGE
COMPENSATION INSURANCE
(This section necdism be complemd ifthe permit is for one hundred!dollars($IM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Icss.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/FLECI'it
not employ any person in any manner so as in become subject to the Worker.' PAID
z Compensutionlawsof CalifOmia. Dae WATLRSYSTEMTIEATING
Applicant Date Reccipta
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PUMP. SQ.FF.
P U') become n
e subjceo the Worker's Campcnsntion provisions of the Labor Code,you must TOTAL:
C�
fears an comply withsuch provisinm or this permit shall be deemed revoked. BUILDING FEE
y CONSTRUCTION LENDING AGENCY SEISMIC FEE
Zz I hereby affirm that hem is a concoction lending agency for the performance of
C) O the work fm which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
D. ry Lender's Name
O t Lc^ders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
r W 1 certify that 1 have read this application and state that the above information is
t— 6. corrtct. lagree mcomply wi@all city.rid county oMinmces ana stake owe relating ho PERMIT ISSUANCE MECHANICAL Ede
_ building construction,and hereby authorim representatives ofthis city memer upon the
V z abovomanio.ad property for inspection purposes. AI;IER OR ADD TO MECH. CONS'IRIICTION TAX
(We)agree m save,indemnify dad keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acemeagairrst said City AIR HANDLING UNIT(TO I qWO CFM)
in consequence of the grunting of this pemhit.
J,), _3 AIR HANDLING UNI'F(OVER 10,050 CFM)
Priamrasl \PPInmum/'C'on'tractor Dole EXHAUST HOOD(W/DUCT)
PAID
IIAZARDOUS MATERIALS DISCLOSURE HFA'TING UNIT TTO 100,000 BTU7 Data Recciptp
Will the rte CrEatarfuturebuildingdccupmtspmor handle Health mematerial
as def tied by the Cupertino Municipal Code,Chirpier 9.12,and the Health and Safety HEATING UNIT(OVER 100,(1(10 DTU) TOT
Code,Seetinn 255320)?
❑Yes 11 No VENTILATION FAN(SINGLE.ftISID)
Will hair contaminants
building by thentuse Area Aen Quality
es Management
BOILER-COMP OHP OR RROW BTU) ISSUANCE DATE
havrdom air contaminants as defined by the Bay Area Air QuelitY Management BOILER-COMP OVER 100.IXq BTU p
Dlstna't l ) P.4
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.EF.
1 have read the harmonious mammals requirements maker Chapter 6.95 of the �
California Health&Safety Code,Section..25505,25533 and 25534. 1 understand that [IiiaI p
if the building does not currently have u¢pmt,that it is my responsibility m notify the
Occupant of the requirements which moot know prior m issuance of a Cenificatc ofOccripart CST
Owner m authorized agent Date TOTAL: ISSUED BY:
OFFICE