24808 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II ILUING-ELEC HICAL PERMIT No' 24808
APPLICATION/PERMIT PLUMB ING.MKCIIANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICA9'ION
BUILDING ADDRESS
��// 1µI µms./�� I /n�y� fin/ SANITARY NO. APPLICA'DON SUBMITTAL DATE:
!� AD P' rrls�-- ✓io UNIT# LOT# � I
O A `sS,yfV/IV VG w CONTRACTORS NAME: LIC NO:
�— N/C CON9'ROLp
1RCIIITECf?NG�ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. F.LIiC'fRIC PERMIT EEG BUILDING PERMIT INFO
A� / q
PERMIT ISSUANCE BLDG ELECT PLUMB MECH
�� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAI. 1 DESCRIPTION
OCZ Thereby affirmrhutl 3tdth Bnxinderprov roftsaf Chapter and mmecense with
[,100 SectiorceadefDivision Jof the Pusinaa and ProfassionsCMe,and my license iv in PANELS
t<IZx� full fnrc Cities feet.
Fy Liceme Cluvs LIC.N UP TO 200 AMPS
mad Data Contractor 201-Hall AMPS
Fyz ARCHITECT'S DECLARATIONOVI3R 1(X10 AMT'S
CZ-0 SQ.FT.POOR AREA S/SQ.IT.
Z O1 undwound my plans shat)be used tis public records.
-o
9-Rd SIGNS ELECfRICAI, y �S L E B �e
�¢ Licensed Professional OWNER-RIIILDF.R UECLARA'1'ION SPECIAL CIRCUITIMISC. r ` f'- p p ���rrr 1� 10-1
°�OaU I hereby uffiren that I am exempt from the Contactor',License Law for the f n L� I-1 La'
W 3 a to following reason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. J J Il l 2 ,I
�Oy� which rcoims a permino construe,alter,improve.demolish,or repair any structure
r°Y� to its issuance,alsore uires the Ideon fmsuch lto file a signedstatement POWER DEVICES
Kty prior y pp permi
W K p0 that he is licensed pursuant to the provision of the Convector's Liecrsu Law(Chapter
4 y0� 9(commencing with Section 7000)of Division 3 ofthe Business and Profession Cade) SWIMMING POOL ELECTRIC VALIDATION
iW_m or that he is eaempnherefrom and the basis for the alleged exemption.Any violation o! OUTLETS-SWITCHES-FIXTURES
F'yQ Sectio ]Or'r'.3 byanyapplicant(oro pe mot subjuu the applicant to a civil penalty of
� ❑
t than RoethepToddollarmyea} n. NEW RESIDENT IAL ELECIA _SQ.ET. STORIES TYPHCONSTRUCTION
ttY 1,aIcwrk,o thcs coy,orm.ti.wodedor ffea ,es mei(, .7o ,Beanies
003— iR hewons ande:The Contractor's
License
La does not
apply
Business
and Professions Code:The Convector',License Lew does or apply to an owner of
Property w yces,provided
tat suchemon,and onsw¢such work himuRonbroughhis
wnempinyea,pnrviJed Nat such improvcmentatirenotimendalorofPortd forsale.If. OCO GROUP, RES UNITS
however,the building or improvement is sold within one yew of completion,the owner-
milder .will have the burden of pruning that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Lrthe project
(Sropeny 1.Business
with dee)The
nectsr
icenconstruct the project plyoc.]OW, nerofp and ywhasions Coded The 1h Connector's PERMIT ISSUANCE
L cense Law does sec aproy tosnowneraf grope s)whobuiIdsm improvesthereon,end
whem,Laws foreuch prnjatswithunmvacrr(e)liccnsed pursuanUothe Convenor's ALTER-DRAIN&VENT-WATER(HA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mann BACK FLOW PROTECT.DEVICE OUT SI)i. I1
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA,GOND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
tint
❑ I hereby affirml hoveacertificamofconsent toself-insure,ora certificate of FIXTURES-PER TRAP RECEIPT#
6W.flocit'
Compensation lneoanceora cimfieJ copy thermf(SwJBa,Lab C.)which PARK FEE Y N
emmoitill con loyee'u under this permit GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy at BUILDING DIVISION FEES
[IComCertified copy is hereby fumishW. GAS-1A.SYSTEM-OVER 4(IA) PLANCHECK FEE
❑ Cenifed copy is filed wi,h,hc city inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OFEXEMPI'ION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM PA.200T. ENERGY IEE
or less.)
I cenify that in the performance of the work for which this permit is issue,I shall WATER HEATER W/VENT/ELECI'R
nm employ any person in vny manner so as to become subject to the Worker% PAID
Compenestionlawsof Celifomia. Date WATER SYSTEMTRHATING Date Receipt#
0 z Applieal
0 NOTICETO APPLICAN9':ILafcr makingthis Certificate trf Exemption,you should NEW RESIDENTIAL PLMB. SQ.F'I'. TOTAL:
V1 become subject to the Worker's Cmnpensation provisions of the Labor Code,you must
fonhwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
L2a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihembyafli... thwdeoe is.consuuction lenlm,it,eney for the performance of
V
the work for which this Permit is issued(Sea 3097,Civ.C.) TOTAL: ELECTRIC FEE 0 Permit Lcndds Name
0 lender',Address QTY. MECHANICALPERMIT FET; PLUMBING FEE
0 V 1 certify that I have read this application send state that the above information is MECHANICAL FEE
LU correct. I agree to comply with all city and county obiinnees and ame laws minting to PERMI'TISSUANCfl
buildiagconwruction,and hembyouthorin mpremoatives ofthisciry manor upon the CONSTRUCTION TAX
L) 7 above-mentionW progeny for inspection purposes. ALTRR OR ADD TO MEC11.
G' (We)agree to save,indemnify and keep lowness Ne City of Cupenino against
liubilitics,jud ts,costsandenpcnseswl hyyy'''ay in y acruetigairst said City AIR HANDLING UNIT(TO 10,003 CFMI
in consrquen the greeting oft spc AIR HANDLING UNIT(OVER 10,"CFM)
31
Sig more of Applican/C ter Date P,I IAIIST HOOD(W/DUC1) PAID
HAZARDOUS Riling MATERIALS DISCLOSURE
HEATING UNIT(TO I00,oa BTU) Dom Receipt If
Will the the Cupnt or ertino
Municipal Code,Cant perrem handle hHealthasmomnal HEATING UNIT(OVER 100,000 BTI) TOTAL:
as C define)by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Swtion 25512(u)'1 13 Yes 13 No VENTILATION PAN(SINGLE RESIT)
Will theupplicwtorfuwrchuilJingacupant use equipmenlordevices whichemit
HOILER-COMP(3I IP OR 1000)1 B'IV) ISSUANCE DA
hvurdous air contaminants as defined by the Bay Amu Air Quality Moro gemenl BOILER-COME(OVER 100,1100 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. A p p#
I have read the how rdom materials requirements under Chapter 6.95 of the
California health&Safety Cone.Sections 25505.25533 and 0534.I understand that /I�
if the building does not currently have a mount.that it is my responsibility to nosily the A
acupant of the requirements which must be met prior r issuance of a Certificate of
acup:mcy. C/- Pill Owner.,amhonred agent Date TOTAL: ISSUEDBY:
OFFICE