24805APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CLPERTINO
BUILDING -ELECTRICAL
APPLICA'T'ION/PERMIT BUILDING PkOJE1'LUMIHN'G-MECHANICAL
BUILDING DIVISION C'1IDENI T:Y'1'IFICA1 ION
PEHMITN0. 24805 arm
2 4 8 05
BUILDING ADD SS: ��(�r�rl�j�✓,
SANITARY NO.
APPLICA'11ON SUIIMITTAL DATE:
2� 6 tel"' — ' " ' UNIT LOT
r�
�iCON'fNOl.p
fJWN' S yfjl /a PIIONF.:
NQ.
NIC
a
D
RCHITECT/ENGI EER' 1 Last, LIC �- f
S. `/V �(- �/�
'O(
CONTACT: PHONE:
Q'TY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
01,IXi I'.F: PLUMB MLCII
El
VK- f(,A^ A6
N 1 Ii4,.• 1
PERMIT ISSUANCE. ICE'at
LICENSED CONTRACTOR'S DECLARATION
Ihctcbyaffirmmat ime1 amlicensedBiunder
all ProfessionsCardr9(commencing with
Section 9(00)nf DivieionJ of me Business and Prufessimns Gde, anJ my license is in
APPLIANCES - RESIDENTIAL
PANELS
JOB D 'CRIPTION
�.$
�VVXX//
roll force and ere
n ,
'Liap J
UP T0200 AMPS
A/
IJmc Cmmm�or
ARCHITECT'S DE RATION
1 understand my plans shall be used as public records.
�
2111 - Iqq AMPS
OVER 1000 AMPS 1
S1'. �R A Ii
`(
S/SQ. Pf.
SIGNS ELECTRICAL
E R
Lmensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
-
I hereby oft ion that I am exempt from the mssionmrs License Law for the
following reason.(Section ]031.5,n.mm ninnJ Ive,cleinns Code: Any city or county
TEMP. MEI'lik OR POLE INS r.
whim requires issuance. permin m liesrum, aper, improve, h PearbsM1. or repair any awmum
prior to file. selaw stmemrnt
POWER DEVICES _
bels lcensedalstano to tethevision stoic Copermium
hat be i,encinwithSeadnnthepn Divissnfthethe Bucmrs License laws (Chapter
9(commencing with Sxnion](00)of Division3nfthe Business and PrnfessionsCWe)
or he is exempttherefrom and the basis for the alleged exemption. Any violation of
Section 703 1.5 by any applicant for a perm mit subjects the applicant a civil penalty of
SWIMMING POOL ELECTRIC
a•ra��.. �ar�a'�� VA�LU
r�ATION
VCJ,Ov(/
OUTLETS - SWITCHES- FIXTURES ,
nf marc than five hundred doll... ($50(h.
❑
wok,
NF.WRFSIDF.NTIALFLECTR SQ.FT.
STORIES
'TYPE CONSTRUCTION
anhepropeny,ormyemployeeswithwagcsasaleyele Business will dothework, and the
oche offered for sale(Sec.]044, Business
he Comennotintendede
and Protevsiom Cada The Cnntmcnn.v Liceme Law Jmes net apply m an owner of
property who builds or improves thereon, and attendees such work himself or through his
ownemployees,pmvidmatsuch improvementsnotintendedmpffemd forsale.IL
OCC. GROUP
RFS. UNITS
.p
however, the building errr improvement is sold within one year or implies for the owner-
builder will have the burden of proving thm he did urn buil] or improve for purpose of
QTY. PLUMBING PERMIT FEE
QTY,
mile.).
❑ owner ofthe property, amexclusively contracting with licensed convenors to
IlooD zorve
npry
Linstruct the project (Sec. 9644. Business and Professions Code:) The Contractor's
icense Lawdmsoot aMlyionnownerofpropcnywhobulldsorimpmves Nemnt.end
PERMITISSUANCE
whocommnsforsuchprojectswimacontractnrts)Ticensedpumaanurrhe Contractor's
himroe Luw.
EA )
ALTER - DRAIN &VENT -WATER( '
FEE SUMMARY
❑ 1 con exempt under Sec. , B & P C for this reason
BACK PLOW PRO'fliCl'. DEVICE
OI'1'SIDE FI:I:S
SANITARY Y N
RECEIPTan
ODate
WORKMAN COMPENSAIWN DECLARATION
hereby affirm that l have a cenilicate ofeonsent to selbireare, or a certificate of
Workers Compensate.hostraireaoraceniGed on, Nemof(Sec. 3900. Esb CJ which
coversPolicy 11 ��tt
DRAINS - FLOORROOF. AREA. COND.
SCHOOLTAX Y N
R17CEIII4
FIXTURES - PER TRAP
PARK ITE. Y N
kDM
GAS -EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEESCompan,
� rr�
GAS - EA. SYSTEM-OVER4(EAA)
PLANCIIFCKPER "L
❑ CenifiMesiIi khcrehyfumishcd.
GREASE/INDUSTRI. WASTE. INTERCEPTOR
GRADING FEE
❑ Cenificd copy is filed wlth the city irepection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS IT?E
COMPENSATION INSURANCE
SIEWER- SANITARY - STORM EA. 2X114.
FNERGY 17EE
('thismainn nceJ not acomerplened ilmepemd is hon -hundred dolbobl$100)
of lass.)
WATER If Ii TER W/VENT/ELECfR
I certify that in the performance of the work for which this permit is issucl.I shall
not employ any person in any manner so :.s to became subject to the Wmrkea'
Contpen,nimni-awam C.1ifnmia. Date
PAID
Date Receipt#
WATER SYS "I EMO REAPING
Applicant
NOTICE TO APPLICANT: If, after mokingthis Certificate of Exemption. you should
NEW REST DENTIAL PLNB. SQ. Ff.
TOTAL:
become subject to the Workers Compensation pmvieons of the I.aher Code, you must
forthwith comply with such provisions or this permit shall be d«med revoked.
BUILDING FEE
Eft 1,41SO
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby mf irm tnal there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
TOTAL:
IiLECIRIC FEE
"Ll MIS I
Lenders Name
QTY. MECHANICAL PIiRMIT PGE
PLUMBING EEE
Lender's Address
I m tify that I have read this application and sate that the above information is
correct. l agree to comply with all city and county ordinances and state laws miming to
PERMIT ISSUANCE
MECHANICAL FEE
building am.vrence. and hereby authorive representatives of this city m enter upon the
abovcmentional property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFMI
m save. " detrulify end lamp hamtless the City. Cupertino agaiw
awhichuy' ny ay acemeagainst said ity
mbilitim.judg ents,cu I m
AIR HANDLING UNIT (OVER 10,M)CFM)
arcroctouscis el g 'sti of permit. S
EXHAUST HOOD(W/DUCI')
PAID
Signaturcnf Applicant/Conlractor Date
It RATING UNIT(TO 100,00) BTU)
IIAY.ARDOUS MATERIALS DISCLOSURE
Date Reccid M
HEATING UNIT (OVER 100.100 BTU)
TOTAL:
Will the applicant or future building circulated store or handle hamfdous material
as defined by the Cupenlna Municipal Code, Chapter 9.12, and the Ilcalth and Safety
VENTILATION FAN (SINGLE RESID)
CWe. Section 25532(x)'
❑ Yea ❑ No
ISSUANCE DATE
Will the applicant or futumbuildingnecupant use eyuipmentordeviveswhlehemh
BOILER-C0MP(3HPOR 100f00131U)
BOILER - COME (OVER 100A00 BTU)PH
Res,ramme ab ernmminants as defined by the Bay Area Air Quality Management
PAID
imrm?
NEW RESID[NI 'IAI. MECII. SQ. Ff.
❑ Yca ❑ No
1 have mad the hazardous materials «yuiremems under Chapter 6.95 of the
Cnllfarniu llc nth&Srfdy CaJq Sections 255115, 255]3 unJ 25534. Imasco ndlhm
awaae��
[NII 5 19Z
�R�aMI11 ,%
film building docs not currently have a mason, that it is my responsibility m notify the
occupant of the myuimmems which must be men prior m issuance of a Crnifiese of
Cu i Ur LUrcn
fxrnnanay.
- nwv
ISSUED BY:
Owner of aoth rove d agent Dale
TOTAL:
OFFICE