24855APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO
N LhlllM:-ELECTR[C-AI.
PERMIT NO.
APPLICATION/PERMIT
PLUMBING -MECHANICAL,
/� (� r
BUILDING DIVISION
IIILDING PROJEcr IDY.NTIFICA'I']ON
VX`55r
C
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SSUUBMI]TTAL DA TE
T ✓
UNIT#
LOT
Ii—I
OWN S G: NE:
CO
NAME,: LIC
P w
NIC
CONTROL
_^
' G]NEE LIC NO:
AD
PSS:
l6d9`t
D S
-El
oN ECT: PHONE:
QTY.
ELECTRIC PERMIT
FEF,
BUILDING PERMIT INFO
B EhE PLUMB MECH
PERMIT ISSUANCE
El
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
)OB DESCRIPTION
1 hereby afm that I am ea licemunderprovisions o'CTapler 9 (commencing with
mmon 7004.f Divisi3 of the Business and Prefcssiom Craft and my license is in
PANELS
�on
full fora and cIf }
UP T0IN)AMPS
License s
Date Commcmr
DIiC1,ARA'TION
201 - IIXIII AMPS
SQ. Ff. FLOOR ARBA
$ISQ. FT.
AIICIIITIiCI'S
EM'
1 undersand my plum shall be used as public m,onds.
OVIiR 11100 AMPS
L q-2
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm That I ren exempt from the Contractors License Law for the
J„
following reason, (Section 01131.5. Business and Professions Code: Any city or county
TEMP11iTl!ft�0 S".iH.N,
which requires a permit to cmnsomel, alter, improve, demolish, or repair any structure
prior a its issuance,alsore9uircs theappllcaalto..mch permiim file a signeastamment
POW[ UftVICE I
that he is licensed pursuant to the previsions of the Contractors License law (Chapter
VALUATIQ'�1
9(commendng with Samoa 70ift Division 3 at the Businessland Professions Code) SWIMMIN�G ELECfRI r
or he is exempt thcrefrem and the basis for the alleged exemption. Any violation of
APOOL
lm EUSDAT IEC
YITY
(/V
4V
S.,morm1U31.5 rte suhjeaxthe apPlicam toacivil penalty of
�/y q
L
$50rmit
handrelicantns($500).
not mom Ihnn five nundrcJ Jullars' ($SW ).
❑ I,nsowncruDheprnpeny,nrmyemployees with wegesmtheirsolecompemation,
NLW
5'I'ORIES
TYI'Ii CONS'RUM '[ON
will do he w.,k,and thewbalum is not intended OrofEmd for sale (See AW, Business
and PmPossi:ms Cale: The Contractors License law does not apply to a owner of
properly who builds or improves thereon, and who does such work hime for through his
OCC GROUP
RIS. UNITS
ow nempl"rees, p mat eh imprUvemw t n d B,
ew ded
the ownale.
wero plebeoffer
ing or improvement Icesold in e of completion,Ireowner-
hdlder
'10
e diinoneyear
baimer wiu nave me Women or proving mat he did nm nmla or improve for pagane or
wiII aveteoren of
sale')'
QTY.
PLUMBING PERMIT
FEE
ZONE
APN
C)I,aaownerofthepmpeny,amexclusivelycontramingwithlicensedcontmctorsto
construct the project (Sec. Il44, Business and Professions Cade:)'Me Contractors
License Law ems not apply maowncrofpmpery who builds orimpmvesmercomand
PERMIT ISSUANCE
who contracts fornuch pmjecu with acomraaads) licensed pursuant a the Contractor's
License law.
ALTER - DRAIN&VENT -WATERFA
( )
PEI? SUMMARY
❑ I am exempt under Sec. , B & PC for this mason
BACK FLOW PROTECT. DEVICE
1'1'SIDE FEES
SANITARY YN
RECEIPTM
"OwnerI Date
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR. ROOF, AREA. COND.
SCHOOI,TAX YN
hereby affirmthit l have acenificale or consent to self -insure, or a certificate of
FIXTURES - PER TRAP
RECEIPTp
PARK FES Y N
N
Wixken' Coniamommn lnsuru orro certified copy thereof(See3800, Lab C.) which
covers all employee's under this tIC
perm:. f.'%4� �96.
PolicyX
GAS-IiA. SYSTEM -1 INC.INC40UllE'1'S
BUILDING DI SIGN IliliS
�
C (
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIIHCK FEE
❑ nificdcopy shemby fum[a ed.
GRADING FEE
jy Certified copy is filed with the city inspection division. GREAS[y1NDUSTRL WASTE: INTERCEPTOR
CERTIFICATE 01: EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEE'
COMPENSATION INSURANCE
ENERGY FEE
('fhiseechad neednot he completed ifthe permit is himine hundred dollars($IOU) SEWER - SANITARY - STORM EA. 200FT.
or less.)
I certify that in the perfnnnace Ofthe work fa which this permit is issued, l shall WATER HEATER WIVENDE:LECUt
not employ any person in any manner so as to become subject to the Workers'
PAID —
Cimpen.aullonlawsof Califomin. Date
WATER SYSTENETREA'DNG
RcceiptI
Applicant
NOTICETO APPLICANT:II.aBer making this Cat[ficac of Esempdoo. You should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
became subject to the Workers Compemalion provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be dcemed revoked.
BUILDING FEE
SEISMIC FEE ` O
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Ihere is a construction lending agency for the performance of
q'OTAL:
ELGCI'RIC FEE
the work for which this permit is issued (Sec. 3097. Co. C.)
PLUMBING FEE
Lenders Name
Lenders Address
QTY.
MECHANICAL PERMIT
FEE
I certify that 1 have mad this application and state that the above information is
MECHANICAL FEE
correct. Tallow to comply with all city and county ordinances and state laws nelatingm
PERMIT ISSUANCE
CONS] RUCTION TAX
building conslrunion and belch, authorize ml resenmtives of this city to enter upon the
above .. edpropertyfewspeemminumoses,
ALTERORADDTOMHCII.
We) agree ve, indemnif and :cep Iwo s the City of Cupertino against
es,judgments.c sp uch yin ywoyucruentpures eld City
AIR HANDLING UNIT(TO 10,"CFM)
"notice ratioit.AIR
HANDLING UNIT (OVER IO,IKK1 CFM)
PAID
Nlid`
rc m' ApplicanVCmnraLot Data EXHAUST HOOD(W/DL)CD
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.000 BTU)
Date Rcecipt#
TA'
Willthe applicant orfumm building occupant store or handle horadous mmerial HEATING UNIT (OVER IW.000 BTU)
as defined by the Cupertino M icipat Code, Chapter 9.12, and me Dealth and Safety
Cads, Section 25532(x)^
❑ Yes Nn
VENTILATION FAN (SINGLE RESIDE
ISSUANCE DATE
Will the applicant or u ������aaaaaarrr'rrrIding m<upatusc N Ifo remmdeviceswhichemit
BO LER-COMP(3HPOR If10,0008'I'U)
P A 9
baurdous air conatnina�fined by the Buy Arca Air Quality Management
BOILER-COMP(OVER IM.MBTU)
DrSVI[1!
❑ Yes No
NEW RESIDENTIAL MECH.—SQ. [T.
MAR:,121993
I have read the M1mamoa.s materials requirements under Chapter 6.95 of the
California Health & Safety Cale. Sections 25505, 25533 and 25534. 1 understain that
if the building does not curemly have a award. that it is my responsibility to notify the
CII I Vr k.urehl VI S
«copal of the requirement which moat be met prior to issnace of a Ceniecrre of
Occupancy.
ISSUED BY:
Owner nn..Ill... edincto Date TOTAL:
OFFICE