24923 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB u,DIN'G-Ia,ICCTRICAL PERMO'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24923_
BUILDING PROJECT IDENTIFICATION
BUILDING
ADDRESS: // �JJ SANITARY NO. APPLICATION SUBMI"YI'ALDA'TE
V �S-`�' UNI'fa LOT#
OWN' NAM -- `PHO -zz z:yONTRACfOR'S NAME: � _ iLC NO: �s N/C CONTRDL#
A HITE /IiNGINIiIiR: LIC NO: ADDRESS �a5 -fibs j//d��il�VA'y-
CONS' �� I I PHONE ZZAI0 QTLY. f//r,EN-L(E�CT�RIC PERMIT •Oi- FEE El BUILDING PCRMIT TNI°O
E)C•/VG+�J'151— BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OReZ I hereby nflirm that lam licensalunderprovlsionsol Chapmr9(commencing with 1 DESCRIPTION
{y00 fullSection
rceandof Division lof the Business and Professions Code.and my license is in PANELS tF
fullforceCladeffcd. `1 j`' .(a
FZW License Class LIC.# 11PT03(NIAMPS ►f ►
FWJCJ
m« Dam Cmincmr 201-1(100 AMPS
F-yj ARCPIITECTS DECLARATION SQ.Er.FLUOR AREA $/SQ.FT.
zco,— I understand my plans shall be,mod in public records. OVER ION)
P
CZ-0
SIGNS ELECTRICAL
Licensed Professiowl p�lIy1
aywV ffiOWNFR-BUILDHR DECLARA'I ION SPECIAL CIRCUIT'/MISC. ® g V
KOa 1 hereby arm that I am exempt from the Contractor's License Law for the u
u13my following rcasnm(Seetion]UJ LS,Business mA Professlnns Code:Any city or county TEMP.METER OR POLE INST. ,_
which requires a Permit to construct,alcor,improve,demolish,or repair any swnure - Imo)
E�}L to issuance.also rex
the applicant for such Permit file a signed statement POWER DEVICES Y I
prior mlui pp Penni Bn
that he is licensed proami m the provisions of the Contractor's License Law(Chirpier
—00 SWIMMING PoUI.ELEC'T'RIC
eeoa 9(armmencing with Scaion]WO)o[Division Jol'the Business and Professions Code) 11!4A'1'ION
or that he is exempt 0cmfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCIIF_S-FI%TURES ItJ�
F T.¢
Section 70315 by any applicant mi
fora Pcttsubjcasthpp
eulicammacivil pend,yof
n ,tame than five hundred dollars(5500).
ML. ❑ I,asownerofthepropeny.ormyemployaawiNwagesastMirsolemmWa tion, NEW RPSIDFNTIAL GLECTR —SQ.Fr. STORIES TYPE QQN$'1'RUCTION
yye willdo the wnrk,und thupmetnm is not intended orofforcd for sale(Secs'l044,Business
and Professions Cale:The Conlremor's License Low dues not apply to an owner of
propertywhobuilds.improves Immer.and whodoesmch work himxlfor through his OCC. RFS.UNITS
own employees,provided that such improvemenis are not intended orofforcd formic.If,
hoax er,be buildingm impmvemenl issold within one ycaofcompletim.rheowner- TO
builder will have the burden of proving that he did not build or improve for purpose of
e Las nwnerofthe property,am exclusively contracting with licensedammr
heca to QTY.
PLUMBING PERMIT FEE FLOOD ZONE APN
n the project(Seo.Il)YL Business and Professions Code:)The Ccnwcmr'a
Lleen.i Law does not apply rem.weerefpropery who huildsnr improves Immicmnod PERMIT ISSUANCE
whoamuactsfor such projects with acontmctm(s)licensed vrsumuo the Contractor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this reasoniES
BACK FLOW PROTECT'.DEVICE,CDEVICE, O SID I
SANITARY Y N
Owner Data DRAINS-BOOR,RIIOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm thin l have acerificale ofcementtoself-insuri cerficam of FIXTURES-PER TRAP RECEIPT'#
Workers Compensation lexamncem a certified copy themef(Sec.380,Lab C.)which PARK FIJI Y N
o all employee's under this Pm ail. GAS-1?A.SYS]EM-1 INC.4 OUTLETS RECEIPT#
Policy It BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenificJ copy is hereby famished.
❑ CenifieJ copy ie filM witM1 Ne city impmtion division. GREA5171NDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERSCREASE'I RAP SOILS FEE
COMPENSATION INSURANCE
(Thisseation iced not be completed ifthe permit is forme hundred dollars($100) SEWER-SANITARY-STORM F.A.200FT. ENERGY IEE
or less.)
I certify that in the performance oflhe work for which this Permit is issued.)shall WATER HEATER W/VENOELECTR
not employ tmy perste in any manner so as in become subject in the Workers' PAID
Crac'mmiml.awsof Califorem, Date WATER SYSTEMITRF,ATNG Date Receipt#
° Z Applicant
Z 0 NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB SQ.FT. TOTAL:
f—' y become subjectto the Workers Compensation provisions of the Labor CWe.you must
7 forthwith comply with such Provision of this permit shall he deemed Revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING ADPCY SBISMIC FEE
UI hereby affirm that them is a construction lending agency for the performance of Q the work for which'his permit is issued(Set.3097,Ci¢CJ TOTAL: EI.ECfRIG FEE
Lender's Name PLUMBING 1•EE
u-' F Lendcrs Address QTY. MECHANICAL P17RMIT FEE
L) 1 certify Ihm 1 hove read thin a,,dridim and stn¢that the masa iofmarnlion is
�^ center.I agree to comply with all city and county ordinances and state laws relating to PERMIT'ISSUANCE MFCHAN[CAL,FEE
Fbuilding constitution.and hereby amhori¢mprcamarives of this city to enter upomhe CONSTRUCTION TAX
J Zumva-meminncd property for inspwlion purfi ALTER OR ADD TO MECH.
(We,)agree to xave,indemnify send keep homeless the City of Cuper .iso against
liabilitics,judgme cosnandaxpensexwhic mayinanywaymcrmagainstsaid City AIR HANDLING UNIT(TO 10,00 CFM)
in oaw'.eaOc ifyi,granting of this AIR HANDLING UNIT(OVER 10.IX0 CFM)
Aiaa
gnaw tfAppllem1/Cnmravt, ¢ lvlop EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOR"BTU) Date Ree
iii
Will the applicant or fuwrc building occupant store or 1, lichazmdons mmenal HHATING UNIT(OVER 10,00 B'1'U) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RISID)
❑Yes ❑No
Will thwpplicmrorfumrcbuildingacupam usecyuipmem ordevices whichcmil
tlOILER-COMPL3HP OR 100,000 BTU) ISSUA GI�DAIi
eT
hazardous air contaminants as defined by ilia Bay Arca Air Quality Management BOILER-COMP(OVER 100,gM)BTU)
District' El Year 3 01993
Yes ❑No NF.W RESIDENTIAL M13CH. SQ.FT.
I have read the haysrdms materials rcqummarls under Chapter 6.95 of the CI I Y Ur wren 1 ser
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand Ih d
if Ihnbuildingdcexnalcurrentlyhoveostober,thinit Is issuance
eramifythe 1
Oc apir of the rcyuiremenls which must be met prior to iasuma o!a Certificate of
oemapaney.
Owner or amhoriced agent Dae TOTAL: ISSUED BY: la )
�_ OFFICE