24735APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINOII I . - ELECTRI -Ah
BUILDING DIVISION APPLICATION/PERMIT IsI,UMBINf.-MKCHANICAL
BUILDING PROJECIDHNI IFICAI']ON
PERM] T NO.
^ A J��
4 II'
L
BUILDINGADDRHSS:
SANI'T'ARY NO.
API'LICATIONSUBMWIALDA'IT
cC ,�1
LaSSoM UNIT# LOT
l• •••i
O RS NAME. ONF:
CI bL VC I'II
0 / C
CONTRACTOR'S N F' LIC NO:
NIC
❑
CON IROLe
MARCH( :C (ENGINEER: LIC NO:
ADDRESS:
CONTACT: p'ION@
6n b ,..li •1 (J,
_I
QTY. ELIiCiRIC PERMIT TEE
BUILDING PERMIT INFO
BLD{i E� PLUMB MECH
L�.I['r4/I/s
1_I J_I
' � p N�L�CI
PIiRMITISSUANCC
LICENSED CONTRACTOR'S DECLARATION
I hereby affimlthat l am liemisedunderpmvincarsof Chepter9(commencingwith
Section 7000)of Division 3 of the Business and Professions Code. and my license is in
full force and effect,
APPLIANCES -RESIDENTIAL,
TOB DESC➢il"f1Qf��
` ( `6L.0
G7
P06 L.
PANELS
LiermeClusx Liaq
UP TO 21q AMPS
Date Contract m
201 - IOW AMPS
ARCHITECTS DECLARATION
1 undustand my plans nM1nll be used as public records.
OVER IOW AMPS
SQ. FT. AREA
_
I J
S/SQ. FT.
i
SIGNS ELECTRICAL
Licensed Professional_
OWNER -BUILDER n the Co AT10M
License taw for the
I hereby affirm.Se that 1 um exempt from the Cantons
SPECIAL CIRCUIT'/MISC.mE
3EMP. METER OR PoLE (NST.
Co
following =son. (Seaton ]OJ L3, Business and improve, demob Cade: Any city m county
which requires a permit or construct, ober, improve, demolish, or repair any awemm
thithers iaaaane smmmmt
_
POWER DEVICES (](i1 L'
of thesuch Coupenniuo Liease Use
tto the
pursuant
9 hr m is licensed verb Division
Sce on the provisions of the Conwcmrs License Pro lawns Coder
Professions Code)
9 (cat ixemithection feeBusinessexemption,
SWIMMING POOL ELECTRIC
VALUATION
he is ochoin and the ps, desemptlno civiny l of
basperrot.nhects the
Section any applicantror$permit subjects the applicant mucivil penalty of
Sectio 7031.emptthapplicnt for
OUTLETS-SWITCIIES-FIXTURES
than
non mom thnn fiv<hundred dollars ($500).
n❑
wneroneprapcny,ormyempl.yeuwithwegeaasthei(Sec. oumpensinen.
NEWRESIDFNTIALELECTR _SQ. PT.
STORIES
will dothewons und erasure a
oche ed an Bus ss
and Csxm: The Contractors Limns. law
Corte: for License does not apply to
not apply m an owner of
eny wholva uch
propenywyces,pdsorintprat es such improve whodcessuchworkNmsfiered hroughhisowti
improvementsxurene eardedmpictiesl Easels.
OCC, GROUP
.TOTAL:
.weer, thebuildividedtprove rl
however,theavet a burdenofpmem is sold within oneyeti or improve forthe owner-
builder will have the burden of proving that Joined not build or improve for puryrmu of
ff
QTY. PLUMBING PERMIT PEE
saf0).
❑ I,as.wnerofthe pmPeny.amexdusivelycumrasing with licensed cantmm.nm
FLOOD ZONE
construct the project (See. ]M4, Business and Rafesaions Code:) The Cantracmrs
Licenselawdce..... pply m an.waer.fpropeny who builds., impmvextheeam. and
PERMIT ISSUANCE
who contracts forsucb projaax with a conrraaons) licensed punuanOo the Contractors se Lew
License.
Lice
ALTER (Pit)
FEF. SUMMARY
❑ em exempt under Sm. , B & PC for this mason
BACK FLOW PROTECT. DEVICE
SANITARY YN
RECEIPT N
Owner Dam
DRAINS -I1MlR, ROOF, ANPA.COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
❑ Thereby affirm thetl havenanificnm Mammm to sdf-inner, nreceni0cem of
WorkerCompensation Immarree.e. certified copy themnf(Sec. 38001 Lab C.) which
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
covers all employee's under this permit.
Policy N
GAS - CA. SYSTEM.I INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (lit)
PLANCHECK FEE
❑ CeniOed copy is hereby famished.
GREASE/INDUSTRI. WASTE INTCRCCPTOR
GRADING FM
❑ Cmifted copy is filed with the city inspection division,
CERTIFICA9'E OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA, 20OFT.
ENERGY FEE
(Thi, senior nerd not be complelcl ifthe permit is foronehuvdred dollars($100)
.less.)
WATER DFATER W/VENDELECIR
I cenify that in the performance of Ne work frrwhich this permit is Issued, l shall
not employ my person in any manner eco as to become subject to the Workers'
PAID
WA' FEB SYSTEM/1'REA1 ING
C ... pcnsaion Lawxof Califomie. Dace
Duro Receipt#
Applicant
NOTICE'1'O APPLICANT If. after making this Cenificam of Esemption, you should
NEW RESIDENTIAL PLMB. SQ, PT.
TO
become subject to the Worker's Compensation provisions (if the Labor Cade, you must
Innhwith comply with such provisions or this Permit shall be deemed revoked.
BUILDING FEF.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is u construction lending agency for the performance of
the work for which thia permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Nmme
Lenders Address
QTY. MF-CHANICALPERMFT PER
PLUMBING FEE
1 cenify than I have read this application and stem that the ethos. information is
correct l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize represcntaives of this city m enter upon the
abnve-mentioned property for inspection puopciaea.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupcnino against
labilities, judgments, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO I0,010 CFM)
tarn Ve of thcgrantioga thio clmit.
'D
/
AIR HANDLING UNIT (OVER 10,0(1(1 CFM)
sure.! Applicant/ ra Um
Y�^��a
6XIIAUST IIOOD (W/DUCT)
PAID
HEATING UNIT (TO I00.0010 BTU)
�gyn,Js(�� IA DOUSMATERIALS DISCLOSURE
Dam Receipt#
011ie. icam or Opium building occupant amre or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Ileulth and Safety
HEATING UNIT (OVER I W,fNq BTU)
TOTA .:
Cede, Section 23312(a)?
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
BOILER- COMP(311POR hiff" BTU)
ISSUANCE DATE
p �l fr,,,I
(,mak D W
Will thea licam orfumrt buildin occupnat useccui
pp g pnmmordeviceswtlichemit
hazardous air contmninnr s a defined by the Bay Area Air Quality Management
District?
BOILER -COMP (OVER 100,000 BTU)
❑Yes El No
+�
FEB JI,
NEW RESIDENTIAL MECH.-SQ. FT.
of the
I have read the hazardous Sections
sa requirements under Chapter understood
Californiaingdo& SafetyCode,Section23303,233]3 and 23334. 1undenwnd that
,
..,.he uildingdceaorimem, which most have a be,that it i, my responsibility itybnntify the
mccupamyI the rcyuiranems which mu.a M mm prior m iaunnce of. a Certificate of
CITY Ur VVI I:.•
o.aaPan.y.
ISSUED BY: _ r'
Owner or amh.dzedagent Date
TOTAL:
OFFICE