24888 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBU1LIJING-ELECTRICAL PERMITNO. /I o
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL �} 8 8
BUILDING PROJECT IUENTIFICAI']ON 8
BUILDINGADDRESS. �a�I� /�+ SANITARY NO. APPLJCAT]ON SUBMI VAL DA'TH
03'7 /s/'10r1d "� UNIT# LOT#
OWNERSN I::v ���� IIIONE: CONT CfOR'S AME: "S 6C6�J LIC NU�(,?� N/C CONIR01.#
IIIT[CT/IiN01 iER: LIC NO: ADDRESS:
ARC : _GdK Cu kr Ai -4 S.C. !FSVSV ❑
CONTACT: PHONE: JTJ ,V ]LONG PERMIT INFO
ELECTRIC PERMIT FEE
Linc 9�s-7ro2�
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECORATION APPLIANCESRESIDENTIAL JOB DESCRIPTION
p y.Z IM1crcby affirm that lam licensed undcrpmvi.ionrnfCbeper9(commenci wish
WOO Section 7")of Division 3 ofthe Business and Pmfessmas Code,and my li ist PANELS ���///���///��`
I+I1—F.: full fume and effect.
FZm License Class Lic.# UP T0200AMPS
qQd Date Contractor 201-1000 AMPS
FyZ, ARCHITECTS DECLARATION SQ,FI'.FLOOR AREA $50,IT.
z'O9' IundemanJ my plans shall be used to public rtcuNa.
OVER IOp0 AMPS
PyFW SIGNS ELECTRICAL I I N
Q j Licensed Proressional I,
r.oeQ OWNER-BUILDFA DFCLARA9'ION SPECIAL CIRCUITIMISC. p
KOaU L hereby affirm than I am exempt frem the Conuacwr.License Law for the
u3�y following movem.(Section 7031.5.Business and Fkofcsiom Code:Any city or county TEMP.METER O0.POLE(NST. m�
l_'urO Q which requires a permit to construct,alter,improve,dcmol ish,or repair my structure
��jY� prior to its issuance,also requires the applicant for such permit m file a signed statement POWER DEVICES
is,W that he is licensed purmantto the provisions of the Comracmes License law(Chapter
W X.T 9(commencingwith Section 70f ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL EL[CTRIC _ VALUATION"
W=y or that he is exempt therefrom and the basiafor the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �OO/1I «/
,-Z>- Section 0031.5 by any applicant for a permit subjects applicam m a civil penally of - V ll//
520mBear ar Five hundred dollars($500). CIR
). NEW RESIDENTIAL ELE _SQ,FT. STORIES 'I'YFE CONS'IRUCION
aeL� ❑ I.asownerofthepropeny,ormyemploymswithwagesastheirsolecompensmion,
6'3— will clothe work,and the strucmm isnot intended orrd'fered foreale(See.7044.Business
mJ Professions Code:The Contractors License law Jtes not apply to an owner of
propenywhobaildsorimprwes thereon,and who Jaessuchwork himselfor though his
WC.GROUT' RIS.UNITS
hown owemployebuildiviJWIprve improvcmcrosurene ourofdorpletio J ferule.IL
however,the have
the
Orden of improvement is hall within one your of completion,the owner
builder will have IM1c buNen of proving that he JiJ nm buil)or improve for purryru of
sale.). QTY. PLUMBING PERMIT FEE
❑ I,as ownerofthe property,amexclusively contracting with liver.uAcommmunm PLWUZONE AIN
construct the project(Sec.7044,Business and Professions Code)no Contractor's .�
Licemsc Law does not apply man owncrol'pro,"Y who milJavr improves thereon,aid PERMIT ISSUANCE
who contracts for such projects w air arommctods)licensed pursoam tome Contractor's
License Luo. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sea ,B&P C for this reasonERS
BACK FLOW PROTECT.DEVICE l LSIDH P
SANI'T'ARY Y N
Owner Dam RFCI71 V1p
DRAINS-FLOOR,R WF,AREA.COND.
WORKMAN COMI'IiNSA'1'ION UECfARAT10N SCIIWL'IAX VN
k• ❑ LhcrchY aflimtthwlhavcaccnilica¢of um.¢nna sdf-Invurc,oruccnifcaI of FIXTURES-PERTRAP /� RECBpF#
Workers'Compenacam Insurance or a certified copy thereof ISec.38(X),Lnb C.)wbich LEFPARK FEE Y N
covers all employees under this le oit. GAS-EA.SYSTEM-I INCA OUTLET'S RDIVISI #
ooiy# BUILDING DIVISION Igil35
Company GAS-fA.SYSTEM-OVER 4(EA) PLANCHECK FEE `
❑ Cenified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GRF.ASEffNDUSTRL WASTE INTERCEPTOR GRADING FRIT
CERTIFICATE OF EXIiMFTION(ROM WORKERS' GREASE'1'RAP SOILS FEE
COMPENSATION INSURANCE
(Thisaaim noodme odcompleted BIN:permit is for one hundred sonars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY IRE
or less.)
I certify that in the perfonnan¢nf the work for which thispemtit is same,Lahull WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lwsof Califomia. Date WATER SYSTF.M/IREATING Date Receipt#
ZZ Applicant
O NOTICE TO APPLICANT':If.after making this Cenifica,of Exemption,you should NEW RFMDEN"f1AL PCMB. SQ.IT, TOTAL:
(•' VJ become subject to Ne Worker's Compensation previsions of the labor Code.you must
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
W ^�
CONSTRUCTION LENDING AGENCY SEISMIC FEE
6.
z (hereby affirm that is oconstmdion lending agenry for the perfurrence of T FLECMIC FRE
U O Be work for which this permit is issued(Sec.3097,Civ.C.)
lander,Name PLUMBING IT
�' F Lenders Address QTY. MECHANICAL PERMIT FEE
O U I ecnify that 1 have read this application and.tae that the above information is MECHANICAL FEE
>. W correct.l agree to comply with all city and county ordinances and scam laws relaing m PERMIT'ISSUANCE
F_ N lamidingcommoo,ion.and herabyauthorixertpruenmtivesof lhiscitymenter upon the CONSIRUCTIONTAX
U z abovcmemioned popery for inspection purposes. ALTER OR ADD TO MUCH.
(We)carte m save,indemnify and keep harmless the City of Cupertino against
Iialilities.juJgments,costs nseawhich may in my way rectueagainsuaid City AIR HANDLING UNIT CFO Hy"CFM)
in ronuquen f the g ng this pe
/�
a AIR HANDLING UNIT(OVER 10.00(i
Sig of Applicmo/Cmrseer iDsas EXHAUST HOLD(W/DUCD PAID
IIA]ARUOUS MATERIALS DISCLOSURE HEATING UNIT ITO 100,000 BTU) Date Receipt#
Will the applicant orfuture building occupant atom or handle harimmus material HEATING ON IT(OVER 100,000 BTU) TOTAL:
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the health and Safety
Code,Section 255320 P VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
' ISSUANCE DATE
Will theapplicamor Tumrebuildingoorapam umeyuipment ordevices whichemil BOILER-COMP(3HP OR 100,001)BTU) IIIA
hazallous air contaminants as defined by the[lay Area Air Quubly Management BOILER-COMP(OVER 100,000 BTU) YY"'
Diann?
11Yea EINo NEW RESIDENTIAL MECH.—SQ.FT. fifA.\K^
2 9
L have read the hazardous m:neri,ts requirements under Chapter 6.95 of the /� F/ 1993
California lle,lth&Safety Code,Sections 25505,25533 and 25534. 1 understand that Chet
free building Joatnm Curcndy moVa lemnt.that it ix my rcalxtmibilhy m notilymm Vf L�I�/'
oafant or the r{ulremoms which const be tel fin m moan,,of a Cenilirme of V
Occupancy.
Owner or nmhorived agent Dec 'O' ISSUI3U BY:
OFFICE