24678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E'ECI'RICAI. PERMITNO. /N 2I /N /sk
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L 4�6J 8
UUILUING P140 J:C'IIDEN'1'IFICA'E'I(IN
BUILDIN•Gr/ASDDRISS: _s SANITARY NO. APPLICAT11ONSUBMITTALDATF.
/ s/V K1 11 kik , UNIT LD1'#
ER:gAME: �PIf( & IG C(I ` 'SNA!vf LIC O:O N!C CONTROLM
+✓il'1 GINFER:M LICNO: ADDRESS: H S •/ ❑
o •\
'�"'t„�Y CGN'I'ACT: PHONE:
QTY. ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
y BLDG ELECT PLUMB MECII
O(Sxa�'�-S�KPFRMITISSUANCE LR71y+ ❑ ❑ ❑
LICENSED CONI RACI'OR'S DECLARA'T'ION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Metz, Ihereby of �to that l sm licensed under provisions of Chapmr9(commencing with
JOO Section 7000)of Division 3 of Ne Business and Profecomes Code.3nd my license is in PANELS t 1+1�
g b full fora and eIf
{/�
<uz Liccns Class Lic.# UPT0200AMPS
y 6 rn Datc — Contract., (}$fCFLL� c9r3 201-IOM AMT'S
Fqz CIIITFCTS DECLARATION SQ.Ff.FLOOR AREA S/SQ.ET.
ZO'OLNC Iunderstand myplana shall heused.poblic records. OVER III00 AMPS I �s\V,■
F,yHul SIGNS ELECTRICAL L t
hN Licensed Professii I OWNER.BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. / ' V ` R
S O rt. 1 hereby seffirn that I am exempt from the Conwctnr's License law for the 1 l
1+130.y following reason lSmion]031.5,Business and Professions Code:Any cirymcounty TEMP.METERORPOLEINST.
O; which¢quires a p<nnit to cunsmtn,alcor,improvn.demolish,nr repair any structure
°'Y� to id issuance,also requires the applicant forsuch permit file a si dshimmem P0W1?It DEVICES
V1s�, prior qui pp p gne
W
C O that he is licensed pursuant to the provision of the Commences License law(Chapter -
2i �' 9commencin SWIMMING POOL ELECTRIC
c (commencing Section Division Business and Professions Code) VALUATION4Q:
or that he isesempnhamfromandthebasisfertileallegedexemption.Anyviolationof pU'I'hETS-SWITCIIPSFIX'IURF_S
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of - Ar
mnot mine ianfive huprOe Mottos(SSM). NEWRESIDENTIAI.CLECTR _SQ.FI'. STORIES TYPE CONSTRUCTION
❑ othe wrk.andepreperty,mmyempinded Garro wed forahefSee.compensiiess
a will dnthewons end the she Comcturs,mences
intended Law
dos net apply 1. a Business
and Professions Cade:The,c n,1w m,License law nch not apply lf hereselfrifl owner iof I
s
pmpertywyees1mh,rsai d tharatherecmandwhodoessuctende conflicted
his
etnpleye.,pmvided lhul:mch lmprovemenbwe not intended orof(<md forests.It. OCG GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofmmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,nsowncrofiepropeny,umexclusively contracting with licensed contmctnsro QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.]094,.Business and Professions CWa:)The Comrectoes
License Lawdoes not apply to onownerof,ninny whobuilds nimprovestbereon,and - PERMIT ISSUANCE
whnesourect,fm such projects withoconwnm(x)licensed punuenl m the Continuance. gL'IiiR-DRAIN&VENT-WATCR(EA) FEE SUMMARY
Li....e Law.
❑ l ata exempt under Site - ,If&P C farina reason 'BACK PLOW PRO'HiCT.DEVICE OUTSIDE FEES
SANITARY YN
,Owner Dae RECEIPT#
DRAINS-FLOOR,ROOP,ARFA.COND. SCHOOLTAX YN
tit WORKMAN COMPENSATION DECLARATION
I hereby affirm that l have u cenificate ofennxem to sif-insure,or o certificate of PIXTURFS-PER TRAP. RECHIPT#
cPoP'ckcc,a Congrenadiou imumne<ora<enifeda+pytherwf(See.3800,Let,C.)which -PARK ITE Y_N
is if
all employee's undenhis pare it RECEIPTY
GAS. ,SYSTT!M-I INC.4011TLET5
"( y EpBUILDING DIVISION FEES
Company GAS-PA.SYSILM-OVFR4(F.A) PLANCHECK ITE
❑ Certified copy is hereby furnished.
NV_I' Certified cnpy is filed with the city inspedinn division. ORFASIVINDUSTRL WASTE IMI ERCEPTOR GRADING FGF.
CERTIFICATE Of:EXEMPTION FROM WORKERS GREASETRAP SOILS FEE ,
COMPENSATION INSURANCE
(This sectionneednot w eloollelei it the permit is for one hundred drills.($100) SEWER-SANITARY-STORM P.A.201FT. ENERGY FFP.
or less.)
I certify that in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELECTR
not employ any person in any mantrcr so as to become subject to the Workers PAID
Compensation lasso(Califomi.. Date-T WATER SYSTRIvIr RPATING Dam Receipt#
O z Applicant Y, '
Z Q NO'I'ICETOAPPLICANT:ILuftcr making] is Certificate of Exemption,you should NEW RESIDENTIAL PLMIL %FI'. TOTAL:
VJ become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall be dccmcd revoked BUILDING PEE --
W la CONSTRUCTION LENDING AGENCY SEISMIC FEE `
I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this pcmtit ix issuM(Sca 3119],Civ.CJ . TOTAL: ELECTRIC FEE
Lender's Name
U Lemder'a Address r - QTY. MECHANICAL PERMIT FEE PLUMBING FUJI
L) I certify thin I have read this il,lualinn nod shim tMl due above information is
M. correct, l agree tocomply with all city andemnty ordinancesand state laws minting to PERMIT ISSUANCE; MECHANICAL FEE
h ,,, buildingcommuction,and hereby e.hodse representativesofthisciry loader upon the CONSIRUCDONTAX
U 'z above-mentioned pmpeny for impaction purposes. ALTER OR ADD TO MECH.
(We)agree u+save,indemnify and keep harodess the City of Cupeninn against
Iiahi Iaics,judgmemv,enslsaud expenses which may in any wary ocerueasp imisaid City AIR HANDLING UN I"T(TO I O.M10 CFM)
Ain c nscquence of the gramin,of this permit AIR
AIR HANDLING UNIT(OVER 10,0011,CFM))
Signal.2 A irnt/Conlmacr la EXITAIJSTHOOD(WMUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100."BTU) Data Receipt#
Will the applicant or future building oecupam shim or handle humardo.malmid HEATING UNIT(OVER 100.000)BTU)
defined by the Cope alum Municipal Code,Chapter 9.12,end the Health and Safety
Calc,Seenor 255J2(a)] ❑No I VENT ILAT10N FAN(SINGLE RESID) still
❑Yes can
\ BOILER-COMP(3HPOR 100,00(1 BIM) 'ISSUANCE DATE
mrfotumbudding occupnm useequipmentordevic.whichemit
Will theappli
Iaanlons air can armormns.defined by The Bay Arca Air Quality Management BOILER-COMP(OVER IM,OIN)BTU) at rXy,
c'? 7 LLl
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ.PT. 1 n
1 have read the hazardous materials requirement,audit,Chapter b.95 of he 1993
Califomiu fiealth&Safety Cale,Sections 255()5,25533 and 25534. 1 eaderala d Nal /1
If daI ilding doosnol comently lievea ter(list it is my mspn.ihn¢y to notify the - GTr L✓r
occupant of the mmm
yuiremes which must t<mprior m issuance of n Cenidcme of
Occupancy. _ - I+UrCIT i g
Owmer m aatharized agent Dine TOTAL: ISSUED BY:
OFFICE