24564 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILD I,'Bi-19LECTRICAL PERMIT NO.
APPLICA'PION/PERMIT PLUMBING,-MECHANICAL.
BUILDING DIVISION BUILDING PROJHE'FIDF.NTIFICATTIIN
BUILDING ADDRESS: w� SANITARY NO. APPL.ICA110N SUBMMIITTE
ALL DA ,
O � ,V UNI L# LOT# ` r4 4/`
OWN' . AME: PHONE: CON1'RACI'OR'SN LICNO: V
LE (- NIC CON'I'N06#
ANCI IfEC1'ENGINBER: LICNO: ir ADDRESS: ❑
CONTACT: PHONfl-
QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
BLDG ELECT PLUMB H
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDEN'T'IAL - -
IhereM1 affirm that l nm licensed under fCat" ) gwi JOB DESCRIPTION
pW.Z Y Pmvllonso p e. ndmmencln th - _
5100 9ectlnn 71NIf1)af Divixion3of the Business and Pro&xslnos Code.and my license is in PANELS
y�j,L❑J full fine,and effect.
`LW License Class Lic.4 UPT02MAMPS �-
rFxa6y Dom Convenor 201-I"AMPS
ZOy Z. ARCHI'IT.CI-S DECLARATION OVER 1000 AMPS SQ.Fp.FLOOR AREA S/SQ.FT.
OZ—M Iunderstand my plans shall be used as public records.
p4tcjWJ SIGNS ELECTRICAL
<W EN Licensed Professional
�Wy 6 ' OWNER-BUILD DECLARATION SPECIAL CIRCUIT/MISC.
OaU 1 hereby affirm than I an,exempt from the Comraam's License Law far the
00'3 tr-y following rcasom(Sem'mn 71111,5,Business:mJ Prmfexainns Code:Any city,or manly TEMP.MET ER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair ally structure
cc
nY� PH to its i cadare.mmreyuirex theaa
pplicam for such Permit to f lesigned summer, POWER DEVICES
We'G p that he is licensed pursuant to the Provisions of the Counatim's License Law(Chapter
des. 9(commencing with Section 7")of Division 3 oflhe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
n,, or lhnt he is steamdremlrom andthe basis for the alleged exemption.Any vmImionof OUTLETS-SWITCIIPS-PIX'NR[S
FZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil permlryof
O not re than five hundred dollars(5500). NEWRFSIDENTIALEL.ECfR Q S .FT.
0 sownerofthepropeny,ormyemployeeswithwagesastheirsolee mpensation, STORIES TYPE;CONSTRUCTION
3 I do the work,and the stmnurc is not intended oroffered outside(Sec.70,4,Business
t d Professions Code:'I'he Contractor's License Law Jens not apply nn un nwne,of
property who builds or improves therenn,and whodoesstch work himselfnnhrough his - - OCC.GROUP HES.UNITS
own employees,provided that such improvemenlsare not intended!oroffered forsale.If,
bnwever,the building or impmvemem is mud within one yannfcompletion,thenwntt- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
tele.).
[:] 1,m ownerofthe property,amexclusivelymnwning with licensedconuacesrsto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sm.7614,Business and Professions Cade:)The Commences
License Lawdoss not applyes a novenerofpropeny whobuildsorimproves lhermn,and PERMIT ISSUANCE
whoconvacts for such projects with aconmuctor(s)licensed persuade o the Contractor's ALTER (EA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,It&P C for this reason DI: E..
BAC-KFLOWPR0'1'FCTP.DRVICE SANITARY Y N
Owner - Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECIAHATION SCHOOL TAX Y N
❑ Ilmereby affirm thatllmavee certificate olcnmenno selLinsum,oro ccnificam of -
FIXTURES-PER TRAP RECEIPT#
Workers Compensation lnsurancearacenified mpythcrrof(Sec.38(lo,Late C.)which PARK FEEYN
c
rsall employee's under this permIA.it. GAS- SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVIiR 4(IA) PLANCHECK FEF,
❑ Certified copy is hereby nourished,
❑ Certified copy is Med with the city inspection division. GREASFANDUSTRL WAS'T'E IND ERCEPI'OR GRADING FEE
CERI'1171CATI:OF EX13MPTION FROM WORKERS' CRI?ASL'TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hemmp]tted iftle,permit is forms,hundred do]].($Um SEWER-SANITARY-STORM EA.200FT. ENERGY FEii
onus.)
I certify that in me performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECfR
nm employ any person in any mention so ns m became subject to the Wmlreri PAID
0 z ACompclion Lawsof California. Date WATER SYSTESVIRIA'IING Dam ec
Reipt#
Applicant
NOTO APPLICANT'.If,after making this Certificate of Exemption,you should NEW RF.SIDF.NfIAI.I'LMB.—SQ Iq'. 10TA1;
Cn become subject to the Worker's Compensation provisions critic lather Code,you must t
I'nnhwith comply with such pmvisinns or this permit shall he deemed revoked. BUILDING hili
0. Q CONSTRUCTION LENDING AGENCY SEISMIC ITE
7 Z Ihereby off that there is a construction lending agency for the performance of
V O tum work for which this penn]l is issued(Sed.3097,Civ.CJ TOTAL: ELECTRIC FEE
I<ndees Name
0 U lenders Address QTY, MECHANICALPERMIT FEE PLUMBING IEE ��
1 certify that I have read this application and acres that the above infarrnation is
acorrect.In to comply with all cit and ordinances and seat,laws refining to PERMIT ISSUANCE ` MECHANICAL FEE
Cn gree pyhe yen yes g
build dratitructiomund horinspectionu mews
'talives nfthis city renter upon the CUNS I HUGE'ION TAX
V 7-r ulssv(WtIP dtospcnyfor inspection keep
. ALTER OR ADD TO MI?CIL
' (W a to save,indemnify and keep amdeas the City of Cupertino against
Iialbu s,jad ,casts. ex maws mayor w lmeagainsl Bait City AIR HANDLING UNIT(TO 10,0110 CFM)
nscgo begrant it. a Ante
1 _/—f AIR HANDLING UNIT(OVER I0,000 CFM)
i m ofA lican antrnnr am EXHAUSTHOOD(W/DUCI)
PAID
IIA'LAHDOUSMATERIAL9 DISCLOS li
BEATING UNIT(TO 100,000 BTU) Data Rmc issis"J
Will the applicant or future huilAing occupant arm or handle hazardous material HEATING UNIT(GV ER 1(1),(81(1 BTU)
rax.Is Ser by the 32m)1 nn Municipal Cada Chapter 9.12,send Ore Ileulcr send Safny
Cuda,Serum 25572(x)! VENT ELATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMPQHPOR I00,00BBTU) —ISS.A4'CEFDATE
Will rheapplicam urlmure builtling occupanmse equipmemur Jeviceswhich emit Imo' '��
huz#Nous it contaminaaB u defined by the Bay Area Air Quality Mon igemem BOILER-COMP(OVER 1(#1,000 RTU)
District? DEC - g 1992
❑Yes ❑No NCW RESIDENTIAL MECH.—SQ.Ff.
1 have read the hazardous materials requirements under Chapter 6.95 of the
Cilifomia health&Safety Code,Sections 25505,25533 and 25534. 1 undershoot that TT Uf (�1,J1-lts"t—
it the building does not curranly have a tenant,that ills my respnnsmulty to and the 'V11Y
eeupanl of the re:mine nota which..at N mel no,to Issuance of a Cenificam of )r" •�
Occupancy. I
Owner or authorised agent Date ISSUED BY:
OFFICE