24669APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL ]UNG - ELEC[ RICAL
PERMIT NO,
APPLICATION/PERMIT
PLUMBING -MECHANICAL
BUILDING DIVISION
IIU I LDING PROJECT 1UENI ]FICATION 24669
BUILDING ADDRESS:
SANITARY NO. SUBMITTAL DATE,
�,XPPLIQVEON
i� L Y l
UNI P# LOTp
O ERSNA PHONE,
0 �.�^��1. . s
a a Y
CONTRACTOR'S NAME: LICNO:• 1 LLL
N/C CONI'ROLM
I' ARCHTTECT/F.NGINEFR: LIC NO:
ADDRESS:
❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
PEE BUILDING PERMIT INFO
BLDO ELECT PLII B MECII
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
❑
LICENSED CONTRACTOR'S DECLARATION
1herebyaffirmthatTum licensedunderprovisionsofC apteT9(cvtmmencingwith
LOB DESCRIPTION
Section 7")of Division 3 of the Business and Perihelions Code, and my license is in
fit I rimce deffect.
PANELS
I License Class Lic.p
UP T0200 AMPS
Dam Contractor
201 - 1000 AMPS
OVER 10MAMPS
SQ. FT. FLOOR AREA S/SQ, M.
ARCHITECTS DRCLARATLON
I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Pndessinnul
ER
OWNER -BUILDER DECLARATION
RA
SPECIAL. CIRCUIT/MIgC,
I heathy affirm em
that 1 exempt from the Commnora license Law for the
1following reason. (Section 7031.5, Business and Professions Code: Any city or county
TEMP. METER OR POLI? INST.
CAF IREL)
I which requires a Onut to construct, alter, improve, demolish, or repair any structuR
Her to its I .... rcc,k. requires the upplicam fursuch permit to file.signed statement
POWER DEVICES
j that he is licensed pursuant to the Provisions of the Contractors License Law (Chapter
f 9(commencing with Section 7") of Division 3 of the Business and Professions Cole)
SWIMMING POOL ELECTRIC
VALUA'T'ION
or that he is exempt therefront and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for o permit s ibjects the applicant to a civ it penalty of
OUTLETS - SWITCHGS- Fl%TURGS
1Kore than Me hundred did]..(S500).
mLasowncrofthe
property, or my employees with wages as their sole compensation,
NfiW RFSIDIiNT1AL F:LECf0. _SQ. PT.
RIES TYPE CONSTRUCTION
i Ido the work.und thesmunum is nm immndcdoroffered for sale (Sec. 7044. Business
and Professions Cade: The Catnmmors License Law does not apply to an owner of
properly whobuildsorimpmvesthemon, andwhod«ssuch work himendfor through his
vGaj
own employees, provided that such impowememsumnot intendedororfered l'ormle. If,
.GROUP RFS. UNITS
however, the building orimprovement is sold within one ycarof completion, the owner-
builder will have the burden of proving Nat he did mai build or improve for purpose of
TOTAL:
sole.).
❑ I, asowner ofthe propcny,vat exdusivelycontracting widlicensed contractors to
QTY. PLUMBING PERMIT
FEL? FLOOD 'lON ANN
construct the project (See. 1044, Business and Professions Code:) *no Contramors
License Law does not apply loan ownerofpropeny who buildsor improves thereon ,and
PERMIT ISSUANCE
forsuch projectswithacontrnemr(s)Iicensed pununmmthe Cnmrunur's
LicenseLLaw.
e.
ALTER (BA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this rtsaon
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
SANITARY O TY E 'EF N
RECEIPT#
N SCHOOL TAX Y
Owner m
WORKMAN O PENSATION DECLARATION
❑ IM1ereby affirm that lhave ecenilicnte ofconsem to xlf-insum, oro modicum of
RECEIPT#
Workers' Compensation Insurance oracenified copy themof(Sec. 380, Lab C.) which
FIXTURES - PER TRAP
PARK PEE Y_N
avers all employees under this permit.
Policy #
GAS - EA. SYSTEM -1 INC. OUTLETS
GAS. V.A. SYSTEM -OVER 4 (EA)
RECEIPT #
BUILDING DIVISION FEES
PLANCHECK PEE.
Company
❑ Cenifed copy is herehy famished.
❑ Certified copy is riled with the city inspection division.
GRHASF✓INDUSTRL WASTE INTERCEPT OR
GRADING FEL'
CERTIFICATE OF EXEMPTION FROM WORKERS
GRFASETRAP
SOILS FEE
COMPENSATION INSURANCE
('ITis section need not hecompleted ifine permit is for one hundred dollars (SIM)
SEWER - SANITARY - STORM EA. 2MFT.
ENERGY FEE
or lest)
WATER I IEATIiR WfVEMT/ELF.CI'R
I certify that in the performance of the work for which this permit is issued, ].shall
not employ any person in any rammer so as to become subject to the Workers'
PAID
Cbmpensuionl.awsof C.1r mi.. Date
WATER SYSTEM/BEATING
Date Receipt
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam M Exemption, you should
NEW RESIDENTIAL PI.MB. SQ, IT.
TOTAL:
become subject to the Worker's Compensation pmvisiom of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed mvoked.
BUILDING IEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the permoncetce of
the work for which this permit is issued (Sec. 3091, Civ. C.)
Lender's Name
TOTAL:2�
(Y1
r^' V ELECTRIC FEE
Lenders Address
QTY. MECHANICALPERMIT
IEE. PLUMBING ME a S-
1 certify that I have read this application and state that the above information is
correct. lagreemcomply with all city and county ordinances and seem laws rcleting to
PI7RMIT ISSUANCE
MECIIAMCAI. PEE?
building construction. and hereby andumim mprexmatives of this city mentor upon the
ahovc-mentioned pmpeny for inspection purpuxs.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
We) agree ve. indemnify and keep harmless the City of Cupcnino against
abilimm.pdg eirtl stsmdcxMnseswMchmuyinmywny=meagainstsaid Ciry
AIR HANDLING UNIT(TO 10,000CFM)
segy:rtce dt rantingof this pe it.
fly
AIR HANDLING UNIT(OVER 10,000CFM)
EXHAUST HOOD(W/DUn)
Signam of ApplicenUC t Hate
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Receipt#
Will the applicant or future building occupant stare m handle hacudous material
''11
2 � Sv
ns defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Ill ATING UNIT (OVER 100,000 BTU)
TOTAL: •
Code, Seml25532(0)?
0Yes El No
VENTILATION FAN (SINGLE RISID)
BOILER - CAMP (3HP OR 100,000 BTU)
ISSUANCE DATE
Will thceppltuanum
building�by nBay
es asame
theAm. Air Quality Marraghemit
hasallous air contaminants m defined by the Bey Arco Air Quality Managemcm
BOILER-COMP(OVER 100,001 BTU)
ff�� pp p Bre
W o v
U'smin?
V'
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. IF
I have read the harurdous mmerml, r,mrornlx under Chapter 6.95 of the
JAN 12 1993
California Health & Safety Cale, Sections Z5505,25533 and 25534. 1 understand that
ifthe building docs are currentlyhavea tenant.that it is myresponsibilitym notify the
cupant of the requirements which must he met prior to iot ance of a Com fere of
1 eth I DVC)
GI UL
Occupancy.
TOTAL:
ISSUED BY: J' 1 Q I%C�i
Owner or authorized ugent Dam
OFFICE