24698APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDI G-ELEC'I'RILAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBINO • MECHANICAL
HUILIII G Pl fl1E "1• DEN'1'IFICAI ION
PHRMITNO. 24698 ^ A A
L k6 k9 �8
BUILDING ADDRESS a I'i )17 u S
UNIT'# LOT#
SANITARY NO.
APPLICATION SUBMITTAL DATE
•-'�i3
OWNERS NAME: PHONE:
CONTRAC'1'ORE NAM& LIC NO:
NIC
❑
CONTROL#
^
ARCHITECT/EHGINEFR: LIC NO:
ADDRESS;
CONTACT: 03r--,TS-1J&
J#•0
Lsw3! —J,y /J&
RtDewmf %�(/ to &(
Q TY ELECTRIC
?R
FEE
BUILDING PERMIT INFO is
BLDG EL PLUM MEC
T71y
PERMITISSUANC
/�
LICENSED CONTRACT 'S DECLARATION
Ihembyti irm Nal l am licensed underprovisionsmfChame"(commencingwish
Section 7000) of Division 3 of the Business and Professions Cade. and my license is in
,Ir, '-R! D IAL
p EI -S'
IDB DESCRIYI'ION
full farce and effect.
Licm. Class Lic. #
2 Pg
{ Dale Contractor
f20I AMPS
ARCHITECTS DECLARATIONOV
I understand my plans shall be used as public records.(}T}1�'
RI"AMP
� S6 "LOURggEA $ISp./e
3�V{
www
GN�LF I
Licensed Professional
OWNER -BUILDER DECLARATION
PECI IRCUI ISC.
I hereby affirm Nat 1 am exempt from the Communes License law for the
�J
TEMP. M• _ OR POLE INST,
following mum, (Section 7031.5, Business and Professions Code: Any city or county
which «quirts a Permit to construct, alar, improve, demolish, or repair my structure
pri.... it. nanance. slmno,mi sthemplicam for such permiuo file. signWammmem
I'OW DEVICES
Our he is licensed pursuant to the provisions of Ne Contracme. License Law(Clummr
9(commencing with Section 70(0)ofDivision Jofthe Business and Protiounns Code)
SWIMMING POOL ELECTRIC
VALUATION
fmmand the basPermitmrtheasegedexemint to civiny l of
orthm h701.5 by any applicant
gedion 7th. bya .permit subjects the applicannoecivil pcnehy of
�a
TV1 ��
I r, SS0
OUTLETS-SWITCHES-IIXTURES
Mrusathan fire hundred dollars
undredicollars
s mwncrofthepropcny, ormycmployeuwith wagceastheirmlecompenmtion,
4
NEWRISIDHbMALELF.CIR_SQ.FT,
STORIIES TYPE CONSTRUCTION
Old othework,andthe structure isnw intendNmoffeud forbade (Sec. 7044, Business
Professions Code: The Commator's Littnx Law does not apply m an owner of
!N
ppertywhobuildsorimprovesthercomand whodoersuch work himulforthrough his
ownemploy=s,Mvidedtheisuchimpmvmenmmnoiinmndedoraffe forsale.ILR
the e buildingor improvement is sold within oneycarofcomplction. the owner.
builder will have the burden ofrowing that he did not build or improve for purpose of
I
.0 ITS
wd tlVY i
`
\>J
le.).
❑ 1, as o e pisjctr (Sec. 044, Il xclus s elyan conaaossionng , C de:) Th Contemn to
construct the project (Sec.... Business and Professions Code:) The Contractors
thereonand
pplymanowacumenopeny, whnsed
QTY. PLUMBING PERMIT FEE
FLOOD AP
E
�.
PERMIT ISSUANCE
whoco tacurfor former puwimpmvcs
whams, raw. fwauch projects with ecantnmor(s)licensed pursuant ..the Contractors
License Law.
ALTER -DRAIN & VENT . WATER (EA)
PEE SUMMARY
❑ 1 am exempt under Sec. , B & P C far this ream.
BACK FLOW PROTECT. DEVICE
SANITARY Y N
RECEIPTX
Owner Dare
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
FI%TURES-PER TRAP
',O Ihembyaffirmthalhaveaccnifiwm of conxm,o self-ivum,an ttnificnte of
Workers Compensation Insurance, Ora cenified copy thertof(Sec. 38W. Lot, CJ whichL
RECFln#
PARK FEE YN
covers all employee's under this permit.
Policy
GAS - PA. SYSTEM -I INC. 4 OUTLETS
RECEEPI' X
BUILDING DIVISION FFES
Company
GAS - EA. SYSTEM -OVER 4 (FA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREAS12ANDUSTRL WASTE INUERC13PTOR
GRADING FEE �.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SORf`FEE w
SEWER - SANITARY - STORM IIA. 2MFT.
ENERGY FEE aaaaa,
This section need not be completed ifthe permit is forms, hundred dollars (SIM)
or IR..)
WATER IIIATER WIVENT/ELECTR
I coolly that in performance of the work for which this Permit is issued. l shall
not employ any person in any manner m as to become subject to the Worken'
PAID
Compmulmaiswsaf Califoram. Dau
Applicant
WATER SYSTEM?BEATING
Data Receipt#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. IT.
TOTAL:
become subject to the Worker's Compensation provision of [be talar Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked
IBUILDING
FEE Lq
CONSTRUCTION LENDING AGENCY
SEISMIC FO
EF,
Iherebyaffirm that there is a construction lcndingagency for the Ndonrumceof
the work far which this panni, is issued (Sec. 3097, Civ. CJ
Lender's Name
T ,��
ELECTRIC FEE
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and state that ,he above information is
l agree to comply with all city and county ordinances and stem laws rclmintlm
PERMIT ISSUANCE IL as-
MECHANICAL PEE 1-"a,correct.
building construction, and hereby.uthorixe representatives o(this city mercer upon the
above-mentioned property for inspection pueposes.
ALTER OR ADD TO MECIL
CONSTRUCI'IONTAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitiu,judgments,eosnmdc%Nnseswhieh ay many way scerueugaint said City
AIRHANDUNGUNIT(T0 UI,Md CFM)
in consequence of the granting of this i,.
AIR IIANDLING UNIT (OVER IB,0M CPM)
EXHAUST IfOOD(WMUCT)
PAID
Si attire Unte
HEATING UNIT UPO IM.Mlii BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data ReceiptX
handle haaafdound Safety
Will the the Cupet or rtino MunicipalCodeng Chapter 9.12.
n defined by the no Municipal Cada Chapter 9.12, and the Heolth and Safely
HEATING UNIT(OVER 1 Own BTU)
T uj
Code, Section 25532sa)?
32p.)?
13 Yes ❑ No
VENTILA•I'[ON FAN (SINGLE RESID)
BOILER- COMP(3HP OR IW,IItXI BTU)
I$ NCE DATE
A i 0
Will the acom un sere building cuwhichcmit
Air
BOILER - COMP(OVER 100,000 BTU)
ftnaroul Bir contaminants as defnnl by ,he Bay Areu Air Queliry Menagcmeat
ism, by the Do, A . Quality
;D,aBlptq
11 Y. C1No
I have read the hamrdm is materials requirements under Chapter 6.95 of the
California Health&Safety Cade. Sections 25505, 25533 and 25534, 1mdcrsmnd that
APR a.F63
1993
OUY Ut
NEW RESIDENTIAL MFCI I. SQ. ITC
if the building does not cunently have a tenure, that it is my miponaihility in notify the
Cur tri
mecupam of the requirements which mus, Is, mel prior,, Mune, of a Cenificnm of
Occupancy.
ISSUED BY:
Owner or ammalaed agent - Data
4
OFFICE