24709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24709
_
BUILDING DIVISION . BUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS:
/ 1WW 19r. UNIT# LOT/� SANITARY NO. APPLICATION SUBMITTAL DATE
OWN AME: PI NE: CONTRACTOR'S NAME: LIC NO: i• / 7
N/C CON'TR L k
AR I CT/ENGI 'R: LfC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �4 F-1 ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
pyy I hereby afirmthal l am licensed under,rovisionsof Chapter9(commeneingwith
POO Section 7000)of Division 3 afthe Business and Professions Code,and my license is in PANELS
,dU full force and eff /s
pQzw License Cls Lia# - UPT02MAMPS C•/I'M/1/✓j I�R/xR
rn Q es Date C.ntrmaoa 4(f 201-IM AMPS
FOy� A CHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR ARA $/SQ.FT.
2—❑ I understand my plans shall be used az public records: AILED
.N.
3 licensed Professional SIGNS ELECTRICAL
O G
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. n �j g'� p e
aF 1 hereby affirm that 1 am exempt from 0e Coniono o License Lew for the a W YF' pU
3 lalc m following re es it Permit to 903L5, t.amass and Professions Code:Any city or county ctur, TEMP.METER OR POLE INST.
y; which requires a pertain to construct.alter,improve,demolish,m repair any ewcmrc
}�
Ed.,1. issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES ATE
C
aQ pa that he is licensed pu redo the provisions ofthe Contractor's License Law(Chapter
ko 9(commencing with Section 900(h.d Division 3.ftha Business and Professions Code) SWIMMING POOL ELECTRIC p`J VALUATION
al.,vi or that he it exempt and the ba.its the alleged
.ppliexemption,Any ilp .Ity.f OUTLETS-SWITCHES-FIXTURES 9 2�
Q Sectinn9031.56yany died"canlfor$11).tsubjects the applicanttoucivil penalty of /
�s q not more than Eve hundred dollars yemp. NEW RESIDENTIAL P.LECTR 5 .FT.
yy� m ❑ othewrk,andeetamey,ormyemployedorofwed forithei(Sec.compensiness —SQ.FT. TYPE CONSTRUCTION
,3� will Professions
C d the she Comiumea 's License
Law
not
apply to on,owner of
and Professions Cale:The Contractor's License Law dces not apply t.an owner of
property who builds or improves thereon,end who dces such work himself edthrough his
ownemployees,lding or imporvemenpis soldnthinime yearroedor.Rion,the o e.If, OCC GROUP RES.UNITS
howeer will avec a burden ofpmentissat he
inoneyem or improve
pm,ox,e f TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
CI
❑ Iowner jest(Sec,
7041,Business
sCoo c)Th Connector's
QTY. PLUMBING PERMIT FEE FLOOD LONE APN
LacersConstruct the project(Sea. o an o Basins and Professions Code:)The Coatmctor's
License Lawdforsucapplytowith ac.fpf.pertywhnsedpumimprovcst Committees
License
PERMIT ISSUANCE
whence Law,forsuch projects withacnntmetor(s)licensedpursuanno the Contractor's ALTER EA FEE SUMMARY
License Law. ( )
❑ I sum exempt under Sec. ,B&P C for thio recon UTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y==N
Owner Date
DRAINS-FLOOR,ROOF,AREA,COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
eCompeaffirm ionthat Insave a urance
ora ler fie ar,timm.f(onsearat to ec.38sure,0,Lab fificale ofC.)which
FIXTURES-PER TRAP RECEIPT it
Worker'Compensation lnsuranceoracmified espy tham.f(Sec.3800,Lab CJwhiah PARK FEE YN
c.versall etp/Igy �u�da�this�Rry. ' RECEIPT#
Policy, {{ 77�~ // TTJJ7� GAS-EA.SYSTEM-I INC.40UTLE1'S BUILDING DIVISION FEES
Company z , zq GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK HE
❑ Cutified copy Is hereby famished. ,
G9-2PIGTiedcopy is filed with the city inspmti.n division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfmmance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR -
mm employ any pen..in any manner so as m become subject to the Workers PAID
z Compensation Laws of Califomia. Date WATER SYSTEM/1'REA1 ING pate Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this CerOficate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
I V) become subject to the Workers Compensation provisions ofthe Labor Code,you must -
forthwith comply with such provisions aphis permit shall be deemed invoked. BUILDING ME
I (� CONST RUCTION LENDING AGENCY SEISMIC FEE �0
j z 1 hereby affirm that hem is a construction lending agency for performance of TOTAL: ELECTRIC FEE
C) the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name PLUMBING FEE
Lender's Address QTY, MECHANICAL PERMIT FEB
I certify that 1 have read this application
..and mate that the sone information is
4 building Iogfeetoon,and herebylcityniz cepresntativeofthis stone lawsration,upon the PERMIT ISSUANCE MECHANICAL FEE
7- above construction,and herebyauthorize uses.matives of thio cirymemer upon the CONSTRUCTION TAX
7 above-mentioae r=yifor inspection purposes. ALTER OR ADD TO MECH..^� (We)agr ants,
save,s an expenses
and keep harmless the City of Cupertino against
inconsequ afthacatsand expenses which may in any way accrue against said City AIR HANDLING UNIT(TO IO,OW CFM)
nseyu ce of the gramin f thi ratan.
z AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of AppliwnUC ntractor ate EXHAUST HOOD OYMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL: e �'
as defined by the Cupertino Municip Code,Chapter 9.12,and the Health and Safety
Coda,Sectio 25532(e)1
El Yes o VENTILATION FAN(SINGLE RESID)
tus
Will tair canicanmrfmure defined by the Bay Arco enmuality Management p
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAI
I
District?
❑Yes NEW RESIDENTIAL MECH. SQ.Ff.
1 have read the hazardous materials requirements under Chapter 6.95 of the JAN 26 1993
California Health& afety Code,Sections 25505,25533 and 25534. I understand that
if the building doe m currently have a tenant,that it is my reeponsibiliry n.notify the
occupant of.f n M1 mtf6lye my notice of a Cemifcam of u� 4'V F pI'11 IIVV
Occupancy. �/1/.(/// n
P
Owner;r6th
Unitedagent - Date TOTAL: ISSU D
OFFICE