24799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO111ILDIN(x-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CRANICAL /I
BUILDING PROJKCT IDEN'I WICA'1']ON 4
799
BUILDING ADDRESS: 4 / / 4 SANITARY NO. NI'LICVDONSUBMITPALDATIi
D I N ✓ /( � 1 /�NITp LO F# �zZ-173
O SN PHONE: COM R'S NAME: ICNO: ✓✓
O Iv.�l/'VI NE: � i b N/C CONf1tOLN �
ARCHITECREN NEER: LIC NO: A61L1RF,5$: r ElLVM3 z
CONTACT: PHONE: a BGILDING PERMIT INFO
Q'I'Y. ELECTRIC PERMIT' FEE
BL ELECT PLUMI) MECED 1f
PERMIT ISSUANCE
LIC17NSED CONTRACI OR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
mccz flimebyaffirmthal am liceneedunderprovisirnsofChaper 9(rommencing with
�i100 Section'/000)offp'D�'iivvision 3 ofthe Business and Professions Code.and my license is in PANELS �� I I / t c (�y�al "�
-Zw cuclen Cl e and ref`'& Lic.# UP102WAMP 1✓OCy/ I��C IT�
y Duro Contractor 'Sts" 201-I"AMPS Sy.FT.FLUOR AREA $/SQ.FT.
zOvzz ARCHITECTS DECLARATION OVER 1000 AMPS
O z on M I understand my plans shall be used as public records.
r y I:W SIGNS ELECTRICAL
Q Y�,'1 licensed Professional
�wci OWNER-BUILDER DECLARATION SPECIAL CIRCUIT C. I`
Oa V I hereby affirm ihm loon exempt from the Commeto/s License Law faf the
LLOm following mason.(Section TOJ LS,Business and Professiom Cade:Any city or county ]'IiMP.METCRO OLEINS ` I 'V
which requires a permit to con some,alter,improve,demolish,or repair any someone POWER DEVIC
y}� prirrmits issuance,also myuiresthe applicant forsuchPermittofile asigned statement
Op shut he is licensed pursuant to 0e poviiinmoof the Conurco's License Law(Chepoer SWIMMING OL ELF,C'11tIC
aao�' 9(commencing with Senion]OW)rfDocon 3ofthe Business and Professions Code) VALUATION }�
y�_,n or that Sectioheises by therefromnt for and a permit s the Wlegedexempti to civiny l
of OUTLETS- 1TCIIFS-IIXTURIS /SJ D' 60
Ta
Section anYdreddamfm$500).osubjects the applicant to civil pcnahy of
Ca not marc than live hundred dollars($5W). NEW RES FNI AL ELECIR _SQ.IT.
am ❑ othe wrk,and epnspmriefmyempdoyees roffemgexamb(Snle cnmpemmiep, STORIES TYPECONSTRUCTION
3— will Bothe wons Code:d Ile tune is nae inorn easeoul Low does of apply t oan Business
and Professions ldsmn'he C sfitmers License Law does not apply lf an owner iof
s
propertywhobuildsnrimproveuiheeogandcros=nsuch ndMoroffe fro le.Is
wnempinYees.provideJ thetsuchimprovementsaenmintcndedrroflared forsale.If, OCC.GROUP RES.UNITS
however,the buileingor improvement ixsoldwithinoney uofcompletion,therwner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
s le.).
❑ I,esownerofthepropeny.amesclusivelycmn ciingwithliuv contractomW QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
common the project(Sec.7014,Business and Prefectures Code:)The Commoner's
License Lawdoesnot apply to an ownerofpropeny whobu ids mimprovesthereon,and PERMIT ISSUANCE
whrcoalown for such projects with a coronations)licensed pursuant tothe Connector's
Lice.Luw AL'TCR-DRAIN&YENT-WATER(EA) FEE SUMMARY
❑ 1 am csempt under Sec. ,B&P C fm Nis mason BACK FLOW PROTECT.DEVICE OF.FE
SANITARY YN
Owner Date RECEIPT
URAINS-FLOCk,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby affirm that l have a certificate of consentto self-insure.m a cenifteae of FIXTURES.PER P RECEIPT#
mkerv'Compensminn lnsuoncenrncenifed copy therenf(Sec.3gW,Leb C.)which PARK PEE Y
rovers all employee's under this lrrmit. ECEIPT'#
GAS-EA.SYSTEM INC.INC40 LOTS BUILDING DIVISION HIS
Policy p
Company - N� GAS-CA.SYSTEM-O IiR4 A) PLANCIIECKFEE
❑ Cenifiedcopyixherebyfumished.
Certified copy is f led with the city inspection division. GREASFJINDUSTRLW INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(This section neednat be completed ifthe permit is forone hundred dollan($1W) SEWER-SANITARY/Sl'OR A.200FT. ENERGY FEE
or less.)
I certify that in the perfarmunce mine work for which this permit is issued,Ishell WATER HEATEREbOYELEC
not employ any person In any Manner so us 1.become subject to the Workers' PAID
Z Campcmaims Laosof Cmifrmio. DaeWATER SYSI'lz REATING Date Receipt#
Applicant
O0 NOTICE TO APPLICANT:IL alter makiagthis Certificate of Exemption,youshould NEW RESIDE. IAL PI.MB. SQ.FT. TOTAL:
t—' � becontesubjen to the Worker's Compensation provisions of the Labor Code,you most
� > forthwith comply will such provisions or this permit shall be deemed revoked. BUILDING FEE
W z FE
CONSTRUCTION LENDING AGENCY SEISMIC E
5 1 hereby offino that there is a canswetion lending agency for the peRmmunce of
U O the work far which this permit is issued(Sec.3090,Civ.C.) TOTAL: ELECTRIC HE
Lender's Name
O U
Lender's e QTY. MECHANICAL PERMIT FEE PLUMBING LITE
1 certify thin iffy thut I have read thio city
and cou and state ohm the uMve information minting is
coned logree to comply with all city reed county ordinances and etas laws relating to PERMIT ISSUANCE MECIIANICAI.FCC
p" building construction,and hereby authorire eprescnmtivesrfohis city toeoer upon the CONSTRUCTION TAX
U Z sav
he-mnninned popery lbr lnspenion purposes. ALI CR OR ADD TO MECH.
(We)agree to save,indemnify and kap hermlesa the City of Cupenina against
liabilities,judgments.costs and expenses whichmay in any way acerrte against said City AIR HANDLIN UN1T(To 10.011(1 •M)
ce of the .tin of 'a pastil 3-�A AIR IIANDLING NIT(OVER Job)CPM)
Signature of Ap cam vac r Dau EXHAUST HOOD(W UCO PAID
UAZARDOUSMAIER1ALSDISCLOSURB IWATING UNIT(TO IBB, TU) Date Receipt Is
Will the applicant or future building occupant see or handle bzardous material
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Heath and Safety HEATING UNIT(OVER BTU)
Cede,Section 2553260] VENTILATION 17AN .INOLE R 'ID)
❑Yes ❑No
Will the applicant or latae buildingoccupantusecyuipmem ordevices whichemit
BOILER-COMP/Hp OR IW,EOtIB ) ISSUANCE DATE
hu rrieli air coinsurance,m dc0ned by the Bay Area Air Quality Management
UistrinBOILER-CO (OVER 100,00D100,00DBTU) ,AR 2 1993
'f
❑Yes ❑No NEW RFSID IAL MECH. .FT.
1 have rand the hnzordoas materials requirements under Chapter 6.95 of the ��I r Ur Quo CI1111IN/
California IleWth&Safety Code.Sections 25505,8533 and 25534. 1 understand that
if the building does nm cuve tly haves honest,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of It
Occupancy. iz
Owarnifr thodzedagem Date TOTAL ISSUED BY:
OFFICE