24569 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOL. TRI AI. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24569
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAGONSUBMITI'ALDATE
M L 1 11j, 4 �-a UNIT# LOTIf
O tins NAME: a PHONE: C RACTOR'S NAME: LIC NO: JJ
IS I O A 03 N/C CONTROL
ARCIi1T-CP/ENGINEER: LIC ADDRESS: ❑
I
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ W ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pmWZ I hereby afBrromat l amlicensed underprovisions ofaapler9(comerenoingwith /�
F+00 Section'L)00)of Division 3 office Business and Pmfessions Cod"m arylicense is in PANELS N
full force and effect' ,� l
FZw License Class_L�LCL Lic.# UP T02fH1AMPS f]
m< Dam Commcm 201-I"AMPS
ZOyARCHITECTS TION OVER light AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O Z—G 1 understand my plans shut]Is usW is a records.
P ; SIGNS ELECTRICAL
9yFLicensed Pmt'essimal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W OI F 1 ngherebymason.
n.(Se that I am exempt from the Contractor's License Lew for the / ® e
1x13 tz•rn following reason(Section]OJLS,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. t ^ (IV
c1 ON; which requires o permit to construct,atler,improve,demolish,or repair any structure
a� print lairs ellaunce,also requires the applicant for such permitto file a signed statement POWER DEVICES r ttr-_
'GJ p 0 tom he a licensed,n reodd ld @e pmvlsions of the Contractor's License Lew(Chapter 1 \ E R
0. m 9 with Section of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC h V �pl JiryT10N
�ote rcommeocing wl ) u .V4
W•-„� n that he is exempt therefrom and the basis for the alleged exemption.Any violation of
ZQ
Section]03 LS by any applicant fore permit subjects the upplicanno acivil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500). DAT
NEW RESIDENTIAL ELECTR _SQ.FT
STORIES TYPE CONSTRUCTION
��� 11I,asowneroftheproMty,ormyemployeeswithwagesastheirsolecompensation,
t'3_ wllldo the work,and the structure enotimended orofferedfor sale(Sm. Business
and Professions Code:The Connector's License Law does not apply in an owner of
progeny whobuilds orimprovestherenn,andwhodoessuchworkhimselforthraughhis
owner to ees,provided thatsuchim OCC.GROUP EAIN
p y provemenms notintendedoroffem forsale.If,
however,the building or improvement is sold within one year ofcorepletion,theowner- .TOTAL: 8zV V
builder will have the burden ofpmving that he did not build or improve for purpose of CJ V
sale.).
'❑ 1,as owmeofthe property,am exclusively contracting with licensed contractors to QTY' PLUMBINGPERMIT FEE FLOOD ZONE
construct the project(Sec.7044,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Lowdoderco pplyto an owneroTropeny whobuilds or improves thereon,and
who contracts for such projects with acontectmod licensed pursuant to the Contmdors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE IDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificare ofcousentto self-insare,or a ceniflcate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a mrtified copy thereof(Sec.JIM,Lab C.)which PARK FEE Y N
covers all eg1 to se's under(h pypn't� RECEIPT N
he TP Lg-111 T1% ��� GAS-EA.SYSTEM-1 INC.40UTLETS BUILDING DIVISION FEES
Company 111 - -1� GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby famish .
Cenifed copy is Bled with the city inspection division. GREASE9NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneednm becompleted lfthe permit is for ono hundred dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the performance of Ne work for which this permit is issued,T shall WATER HEATER W/VENT/ELECTR
not employ any Nclon in my es to ec abject to the Workers PAID
Compcnsution ws Colifomia a eo v on WATER SYSTEMnREATING Date Receipt#
Z Applicun
Z
NO`UCItT MLI NT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
y become suM1J or h orker's Compensation provisions of the Labor Code,you mutt
tai forthwith comp h such provisions or this permit shall be deemed revoked. # BUILDING FEE
a [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
V 7-. 1 hereby afllrm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3057,Civ.C.) TOTAL: ELECTRIC PEE
Lender's Name
C) Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LUkI1 certify that I have reed this application and stain that the above information is MECHANICAL FEE
Rc correct l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE
building construction,and hereby authorize representatives ofthiscity to enter upon the CONSTRUCTION TAX
V 7 aMve-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
.^y (We)ogres to save,Indemnify and keep hordes,the City of Caperton against
liabilities,judgments,costs and expenses which may in any way accrue agaidetsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicant/Cin meer Date EXHAUST HOOD(W/DUCH
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant Now or handle hazardous material HEATING UNIT(OVER 100,[gO BTU) TOTAL:
u defined by the Cupertino Mu icipat Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE REBID)
❑Yes No ISS^ ATE
Will theapplicootorfumrehuildingoccupantuseequipmentordeviceswhichemit BOILER-COME(3HP OR IM.000 BTU)
xhict9 air rnntaminants as Toed by the Be,Area Air Quality Management BOILER-COME(OVER 100,1100 BTU) JAN
N 1 4 1993
Tat al d/�IV Dal
❑Yea No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the 011 Y of Ll rrn i IPIQ
Cul'omia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that -
i 'iifthe building does not currently have demand.that it is my responsibility to notify the
cope o the mqunene B ich must me once of o Certificate of
IxC nay
ra thorized agent Dace TOTAL: ISSUED BY: —"� I•'•
OFFICE