24674APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO- BNLDING-ELECTRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJRCr IDENTIFICATION
PERMITNO.
24674
BUILDING ADDRESS:
SANITARY NO.
APPI.ICATIONSUBMIT^I'ALDATIi
^
AwqUNITX LOT
OWNERS AM PHONE:
CO CfOR'. NAME:NMrt LIC NO:
N/C
CON '1'RGLp
RCHITF. '/ HNEER: LIC NO:
ADDRESS: '7
❑
CONTACT: PHONE:BUILDING
QTY. ELECTRIC PERMIT FEE
PERMIT INTO
BL ELECT PLUMB MF.CII
PERMIT ISSUANCE
El El El
CONTRACTOR'SDECIARATION
I hereby affirm thatI am licensed under Mm ovisiuofCTapmr9 (commencing with
APPLIANCES-RESIDENTIAh
)OB DESCRIPTION
Section 7000) of Division 3 of the Busincssand Professions Code, and my license is in
PANELS
full force and effect.
Liven,�Claspp���� Lic. Xall
Da¢�G�.M�y�Contracwr Q
�• ����a//ssRC111TEC1'S DEC. A'I'ION
1 understand my plans sIm11 be used as public records.
UP TO 200 AMPS
2UI-Iqp AMPS
SU. F1'. FLOOR AREA
8 I
S/SQ. FT.
OVER 1000 AMPS --
SIGNSELECIRHI L
Licensed Professionaliaaiiii,iii
CRA HUNommone
OWNER-exem t fr.. he
I hereby affirm that 1 am exempt from IM1r fasoms rs License low for me
following mason. (Section 7033.5. Business and Professions Code: Any city orcovoty
SPECIAL CIRCUIT/MI5 .ex
TEMP. MBIER OR POL f
which rtyuircs a permit to cnnstrvct alter, improve, Demolish, (ir repair any slm<wre
prior to its issuance, also requires the applicant for such permit to file a signedamtcmcnt
POWERDI:VICES
,hot he is licensed pursuanuo the provisions of the Contractor's License Law (Chapter
meneir,with Section 7")of Division 3ofthe Business and Professions Code)
9(com
SWIMMING POO�ULECTRIC
J
orthat he is exemptnherefrom and the basis for the alleged exemption. Any violation of
Section "111315 by tiny applicant Ran pernil subjects the applicant to a civil penalty of
OUTLETS-SWITCIIF.S-FI%TURES
wVA�LUATILLN�
f_0,
` YV1
—V
no, more team five hundred dollars(550f. ❑ I,mownerofthe property, mmyeroployseswith wages rouMirsolecompensmion,
NEW RFSIDFNTIALELECTR _SQ. Ff.
STORIES
TYPE CONSTRUCTION
will do the work, and the structure is not imendedoreffercJ for sale (Stt. 7044. Business
and Professions Code: The Contractors License Law does not apply to on owner of
property, who builds ar improves Ihcrcon..J whodoes such work himself m through his
employess.pmvided that.such improvemermare not intendedorofiend forsale. If.
OCC. GROUP
RES. UNIT'S
TOTAI:
however, the building or Improvement is sold within one year ofromplesinn, the owner.
builder wil I have the burden of proving that he did not buildour improve for purpase of
QTY. PLUMBING PERMIT FEE
sale')'
wnerof thepropenY.am exclusively conmacting with licenudconranonm
FLOOD ZONE
APN
moved do, projml (Si 7044, Business and Profession, Core) The Contractor's
License lnwdoes nalapplym anownerofpmpeny wh.1mild, or improves thereon,and
PERMIT ISSUANCES
whocontracn fm.soch pmjcets with aconerroun a) licenud pursuant to the Contractor's
Licenu Law.
ALTER - DRAIN &VENT -WATER (HA)
TEE SUMMARY
El um exempt under Sce. , 11 K P C for this reason
BACK 171 -OW .OW PRTECT. DEVICE
OUISI DL FEES
SANITARY Y N
RECEIPT
Owner ZA ENData
WORKMAN COMPS T O )F.CLARATION
'❑ lbsmbyaffrnnhallhaveacenificamofconsemtoself-insum,oraccnificamof
Workem' Compensation lnmmaceur a ceni0ed copy therecof(Sm. 3800, Lab C.) which
coven all employee's under this permit.
Policy X
DRAINS -FLOOR, ROOF. ARFA,COND.
SCHOOLTAX YN
RECEIPrX
FIXTURES-PER'IRAP
I
PARK FEIN Y N
RECEIPT #
GAS - EA. SYSIIEM4 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM OVER 4 TDO
PLANCIIECK FEE
❑ Certified! copy is hereby fumishW.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cert fled copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS
GREASETRAP
SOILS FEES
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY ME
(This section conduct be camplemd lithe ymmil is for one hundred dollars($]IS))
or lesc)
WATER HEATER W/VEN'f/ELHCfR
PAID
Dam Receipt#
I certify that inlhe performance of he work for which this permit is issued. l shall
not employ any person in any, manner w as to become subject to the Wadi
Compeneaflin Lawxnf Califomia. Data
WATER SYSTEM/BEATING
Applicant
NOTICI2 TO APPLICANT: if. after asking this Certificate of Exemption. you should
NEW RISE DENTAL PLMB. SQ. IT.
TOTAL:
become subject ratio, Worker's Compensation provisions of the Inbar Cade, you most
forthwith comply with such provi store or This parsnh shall be deemed revoked.
BUILDING FEE It
SEISMIC EYE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency for the per fammunce of
the work for which his permit Is issued (See. 3097, Civ. CJ
TOTAL:
ELECTRIC FEB
QTY. MECHANICAL PERMIT FEE
PLUMBING FEF.
Lender's Name
Lenders Address
1 artily that 1 have read this application and scam that he above information is
correct. l agree to comply will) all city and county ordinances and state laws relating to
FERMI'I ISSUANCE
MECHANICAL REE
building conswction.and hereby authorize representatives ofthis city toenmrupon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECI I.
CONS 'IRUC ION TAX
AIR HAS DUNG UNIT (TO 10.000 CFM)
(We) agree hr save, indemnify and keep hamdcss the City of Cupcnino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
AIR tIANDLING UNIT (OVER 10.000 CIM)
in consequence of the granting of this permit.
(EXHAUST HOOD (W/DUC'1)
PAID
Signature of Applicant/Communtnr Dam
HEATING UNIT (TO 100,IXq BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt X
HEATING ONI'1'(OVIiR 100.00 BT' U)
TOT'A L:
Will the applicant or Tulare building (a cupant store or handle havandous terminal
as defined by the Cupertino Municipal Cala Chapter 9.12, and the l twill) and Safety
VENTILATION PAN (SINGLE RESID)
Lai
Cada Section 255321a)7
❑ Yes ❑ No
whiche
equipnuordevices mit
Will Neapplicant orfmuu builJingox:cupanmwm
BOILER- COMP(3HP OR Iff,did B'I'U)
p
p AB�ISSUANCE DA9'E ,
i {J
hazardous air emotion mars as defined by the Bay Arta Air Quality Management
BOILER. COMP (OVER 103,000 BTU)
ionc ❑Ycs ❑Nu
AN 41993
NEW RESIDENTIAL MECH. SQ.lel'.
I have read the hazaMous materials requirements under Chapter 6.95 of the
Culdt.... in Hisilth & Sarmy Cm1e, Sections 255115, 25533 sad 21534. I undersmnd that
ifthe building does nor cuhave a tenant, that it is my responsibility to notify the
case est of the mquircmcnts which man act prim m issuance of a Certificate of
cc u
f;V ULGn MVV
�y ur
/V
CI
I �I-93
Ons or aumotiud agent Data
w
ISSUED BY:
TOTAL:
OFFICE