24607 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOUIL ING,ELEC'T'RICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL f] ^4 O
BUILDING PROJECT L IDENTIFICATION
BUILDING ADDRESS:
SANITARY 0. APP1LICATIONSUBM,ITATTALBDADATE
O� W ki-a--,
UNIT# LOTH
OW i N MIi: CONT LI
q/ [il� gpN{8.;ye�gG�i N M^ 1! N/C CONTROI.M
ARCI ID ECI'/ENGINCER: LIC NOr l AfW Y ❑
C TACT; PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUME MHC(
PERMIT'ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN'1'IAI. TOB DESCRIIr110N
Maty Ih[r[hyuTimubml am licensed underprovisioneefClaptef9(centmencing with
Vs00 Section 7 xm of Dbisinn3 m ire Business and Pmfessions ate and ni'doemseism PANELS
ce V 3 full fart[amt cff rn
FZTz1 Licenx Cla Licp UP TO 210 AMPS /
y6y Date—/�T{'f� Conua[lor 201-I"AMPS
ZFONZ '—s-1 ARCHITECTS DEC OVER IM AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall be used m public records.
F Yt w SIGNS ELECTRICAL
-,j Licensed Professional
-d.C6 OWNER-BUILDER DECLARATION SPECIAL CIRCUI'DMISC.
O y F 1 hereby uffinu that 1 am exempt from the Commmme.License Law for the
W vi following rematt.(Section 7031.5,Business and professions Cade:Any thy TEMP.METER OR POLE INST.
LLO
FCFC which requires a permit to comenuen,.]air.improve,Jenmlish,of repair any structure
dW�a7 priorm id issuance,also requires the applicant for such pemtii To file a signed wmement POWER DEVICES
p�L5p0 that he is licensed pursuant mthe provisions of the Comrade/,License Law(Chapter
9(mmmencing with Semina 9000)nf Divisinn3oDhe 11 a,,real Professions Cade) SWIMMING POOL ELECTRIC VALUATION
1❑y orthat he isexentpnherefrom and thebasis fonheullegedembiluinn.Any vinl.lms,if OUTLETS
t,Za Section 70315 byany.pplicant psmahy fnrepermit subjects the upplinmt mncivil of r
nomm
t othan live hundred dollars($500). NEW RPSIDENOAI.F.LECTR _SQ.FT.
W ❑ I,mowneroftheprnpeny,ormyemploymswithwagesastheirsolecompensation, STORIES 'TYPE CONST RUCTION
a3— will do the work,and the structure is act intended or offered for sale(Sec. Business
and Pmfeaainna Cale:The Coronations License Law does not apply to as owner of
property who builds or improves thereon,and who docs such work himselfor through his tn1 t
own employees,pmvidedthetsvchimpmvememaarenotinrcndW oroffercAfosnde.l6 �11 ( OCC.GROUP RIS.UNITS
however.the building or improvement is sold within one year ofrompletion,the owner- " ' ... AL:
builder will have the burden of proving that he did tun build or Impose:for purpose of -- - is /
sale.). e..-.
❑ I,asowneroflbepropeny,mexclusivelycomractingwithlicen&Mcntmm.vto 1Y. .i "w PLUMB PERMIT IEE Fl.00D 20NE APN
nsham the Police,(See.7044,Business and Professions Codc:)The Contractor's
License l.aw does net apply m anownerofpfepen,whobuildsmmaprovca thersommad IT'1SSUAN i
who cnmmms fnnuch projects with.contractor(s)IicemcJ pu
Lironm Law. rtuum To the Com .AT'IR'=DRAIN�LVNT-WATER(EA)) FEE SUMMARY
o
❑ 1 tun exempt under See ,B AS P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDC I I I.S
SANITARY Y N
Own( Data• DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT 41 r WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
kT T hereby affirm that l have a certificate afconsentto elf-insure,or a certificate of FlX'1LRES-PL•R TRAP RECEIITN
c al Cnmpens m�l�muranceo nified<upy tlerc L(,SCc.'AOU,Lab C.)whi<h PARK FEE Y N
rovers all en.p�In7�u77yy ty sstt// rt �e DDGG33CC// r[— OAS-P REC ISION
S.SYSTIiM-I INC.4 OGfLETS
Policy p BUILDING DIVISION FEfS
Compay Jr},�Ie�x�(„(QJt p, GAS-EA.SYSI'E—OVER4(EA) PLANCHECK FEE
❑ [nlfied copy is hercbylurbisbed.
enifial copy is filed with The city inspection division. GREASI20NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This.eminnneedimbecompleicd iftheperm,isfornnchundreddollars($100) SEWER-SAN["TARY-STORM EA.200FT. ENERGY FEE
or less.)
I etnily t hat in the pefformince of the work far which This permit is issued,I shall WATER I IHATITS W/VEN/ELFM
not ampiny any person in any m.mnef sn us to become subpnn to the Writers' PAID
Compcnsnlinn Lnwsaf California. Date WA'I'HRSYS'IHMGREA'I'ING Date Receipt#
0 z Appli[aul
z NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RHSIDIiNI'IAI.PI.MB. SQ,FP. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
� ; fenhwith comply with such provisieasor This permi t shall h[damad revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby offirm that hem is a construction lending agency for the performance of
V O the work fin which this permit is issued(Set.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
0 L) Ixnder's Address QTY. MECHANICAL PERMIT FEE PLUMNING FEE
I certify that I have read this application and and.that the above infotmmion is
�" a rnrrca. legrcc artomply with ell city and munry ardinancesend smmlawsrel.dngm PERMIT ISSUANCE , MECHANICAL FEF.
F'' building mnmrucbmn,and herebyauthorize represemativeaofluticity loemer upon the CONSTRUCTIONTAX
U 7 nbnve-mer icord progeny for inspcmam purposes. ALTIiR OR AUD TO MLCII.
G (We t save,indemnify an keep h e City of Cupenine against
liubilitie. jt rmnn,,.111midespers ayia..Yw.y acerae geinsLsuid City AIR I IANDLINGUNIT(TO 10,000CFM)
const sect ngmnti go ������� AIRIIANDLING UNIT(OVHR 0000CFM)
Signature of Applicant/Contractor Data EXHAUST 11001) W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE I11iATING UNIT(TO 1011,000 BTU) ✓ Date Receipt#
Will the applicant or(more building occupant store or handle hazardous material
as Jelled by The Cupertino Municipal Cade,Chapter 9.12,and the Ilealth and Safety HEATING UNIT(OVER 100,"BTU) TO'1'AI,:
Code.Section 23372(a)?
❑Yes ❑No VEN H.AI'ION PAN(SINGLE RESID)
Will The acommitoets us building by thenTuseequipment Quality
which emit
BOILER-COMP OIIF OR 100,IXp BTT) ISSUANCE,DATE
• Minim sea air contaminants as defined by The Bay Area Air Quality Mane6emenl BOILER.COMP(OVER 100,1100 BTU)
Oistrin't
Cl Yee ❑No NEW RESIDENI'IAl.MECH. SQ.PP.
I have read The bamfdous materials requirements under Chapter 6.95 of the B' a
California I Ie:JTb A Safety CnJe,Sections 255(15,25533 unA 25534. I undmsmnd that
ifTtipand dingdtusaimmmundyhavcost Theme,
prior my issuance
ofla Tnnrnify the �� ��
ecntryun of The rcquiremoms which must bo ma pylar to issmmm of a Certificate of
fkmtpuncy.
Owner or authorized agent Date TOTAL: ISSUEDAY:
OFFICE