24663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
B 11.111NG-ELECTRIC\I. PERMIT NO.
CITY OF CUPIiR'PINO rl.u.\uuNr,-mECxdN'ICAL 24663
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDEN'ITFICATION r:
BUILDING ADDRESS: -1 — OIDQ H
SANIINRYNO. APPLICATIONSUBMTAL DAII
�ZO27 IPtc II"'_'_ LOTn l?
Ow RS NAF PHONE: CONT ACTOR5 NAME: LIC N0: NIC CONTROL p
RCHITECT/ENGINEER: 'NO: AU
SlAgif
CONTACT: PHONE: - BUILDING PERMIT INFO
QTY. i �'-'ELECTRIC PERMIT.r ;, FEE-' -�
1. G .ECT PLUMB MEC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
DESc IP�IION
nucz Ihiembyaicenudunderprofvsiosofr9(cummencing with
UCO Seclin ofDi1,lm.3,aBusinessu ProfeasioiaCode, my -
�.
license)sin PANELS
u F fall force and of 4 I
�U Y UP TO n_W AMPS
FZ W License Clan Lica Z
rn�y -an..... 201-BOB AMPS SQ.FT.FLOOR ARCA SISQ.FT.
ARCHITECTS DECLARATION OVER IBUB ASIPS
CZ-0 lundcrsmnd my plane shall as public records. �� t�
[-NF; SIGNS ELECTRICAL T _ l j
iJ Licensed Prafesdonal -
xzs< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. J jl .I '�^ f�
C a 1 hereby affirm that 1 am exempt from the Contractors License Law for the U tl Ir`� ,F{`
Wil_ Oy followingressuo.(Serlmn]03L5,Business and Pmfasions Cwle:Anycitymcounty TEMP.METER OR POLE.INST.
which requires a perms to construct,alter,improve,demolish,or repair any structure
prior to in issuance.also requires the applicant for such permitto file a signed sutemenr POWER DEVICES TE
x s QECTRIC POOL ELECTRIC L
p Nat he is licensed pursuant to the Provision of the Contractors License W w(Chap rr
=ZDx 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SVALUTMN
V^N or that he is exempt herefmm andthe basis for the alleged exemption.Any violation ofUTLETS-SwRCtiFS-FIXTURES Z
FZQ Section 1031.5 by any applicant for ap mart subjects jecthe applicant to a civil penalty of
i-C not mote than five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT.
zF� ❑ I,aowneroftheproperty.ormyemployeuwiNwagesmtheirsolecompensaUon, STORIES TYPE CONSTRUCTION
will dothe work.and the structure float imendedoroffered mbase(Sec.]BN,Business
and Professions Code:The Contractors License Law doer not apply to an owner of
propsnywhoballdsor improvelmeteon.and whodoes such work himselfor throughhis
own employon.provided thatsuch improvementsme not in¢ndedoroffered forsole.If. OCCGROUP RES.UNITS
however.the building or improvement is slid within one yearofcempletion,the owner-
builder will have the burden of proving that he did not build or improve for pu i se of
sale.).
L as ownerolthe m n amexclusivd main th licenudconaanors to Qom' g' .PLUMBING PERMIT s�� - }r�FEEt'1, FLOOD ZONE APN
common,the project(Sec.]Uta.Business and Professions Cade:)The Cuntraa
Liamc LawJcesnot apply loan ownermfproperty whobuilds urimpmN
vca erean,andnd PERMIT ISSUANCE
who manners for such projects with acontractor(s)licensed pun uanuothe Contractors ALTER-DRAIN&VENT-WATERA -
License Law.
(EAJ 'r :,7,FEE SUMMARY;
❑ 1 an exempt under Sec. .B&P C for this reasonBACK FLOW PROTECT'.DEVICE O (SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLT'AX YN
❑ Iherebyaffmmthallhareacenlfrc teofcomm�uuwl6imum,orawnificamofFlXTUREg-ppR TRAP RECENTis
Worker'Compensation lasumnmoruenified copy Nereaf(Sec.3800,Lab C,)which PARK FEE Y N
vers ell employee's under Nis permit. OAS-EA.SYSTEM-I INC.a OUTLETS RECEIPT p
Policy p BUILDING DIVISION FEES
Co ray GAS-FLA.SYSTEM-OVER4(EA) PLANCHECKFBE
enifed copy is hercby famished.
Certified copy is filed with ifecity inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenifythat in the performance of the work for which Nis permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any perann to any rouser to become subject to the Worker' PAID
Cmmpcmmion Lawsof Calinmiu. Date a WATER SYSTEMNREATING Dae Receiptp
zZ Applicant
0 NOTICE TO APPLICANT:IL after makingthis Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
VJ beeome subject the Worker's Compensation provision of the Labor Cale,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
u
LEIQ CONSTRUCTION LENDING AGENCY SEISM IC FT:E
a.
1 hereby affirm that there is a construction lending agency fur the performance of
'a Z TOTAL: ELECTRIC FEE
U O the work far which this permit is issued(Sic 309],Civ.C.) -
UndersName
5 �t t'F Lender's Address QTY.',?}, .MECHANICAL:PERMIT„'i�5f;�r, .'s5.tilPLUMBING FEE
U U 1 certify that 1 have mad his upplicutiun and stare that the above information is ` � MECHANICAL Ff:E
�-' correct.lagree mcontply with all city and county ordinances and state laws relining to PERMIT ISSUANCE
F-' building comparison.and hereby arthritic represenutives of this city to enter uponthe CONSTRUCTION TAX
U Z above'mentimmed pmpcny for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities udgments.cmtr Jexpenseswtf h may in any way accmcagairm mid City AIR HANDLING UNIT(TO 10.000 CFM)
ceofthicumnti •o1 this pe' AIR HANDLING UNIT(OVER IBdIDBCI i
Is
Si tare.Ap c.YComrsmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,(X00 BTU) Uat Rcccip
Wi53.
ll the npPlicam ur fuwre buildingoc<upam emrc or handle mradoasmamnalHEATING UNIT(OVER 100.000 BI U)
TOTAL:
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 61 k
❑Ysln(a)n ❑ No VENTILATION FAN(SINGLE RISIDI t
ISSUANCE DATE
Will the applicamor fu a c huilifirgoccupatior usecluipmentode a wldchemit BOILER-COMPOUPOR 100,001)BTU)
amdmc,airc.a...morn a defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
i.nocf! -
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have real the Safety
Code
materials requirements under 3a 1 o 695 of the m 1993
-1
if C,fthe
uil Ingo&Safctyenery See avec meant.
and255W. IandcrstanJthin
ifthebuildingdoesatments yhavea .nuns,thato is my responsibilitynnotify the still
oecupam al the reyuircrnemv which must he mm prim to issuance of a Cenificae of l�I I`{ :if rs.. -`y I
Occupancy.
Owncrnr-amhorlmdagcm Dun 'D ISSUED I{y:
OFFICE