24657APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIJILDING ELKCTFUCAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -JEMECHANICAL
BUILDING PROCT' IDENTIFICATION
PE.RMITNO.
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24657
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BUILDINGAADDDRESS:
SANITARY NO.
APPLICATIONSUBMUTALDATE
J /1 {�
Lv, -
/O�JrTI/� _ Llt44v, UNI'TN LOIN
OWERS NAMI?: PHONE:
- F!
COM' CIOR'S NAME: �LIC Nom.
U - GT Oa- yr
N/C
❑
CONTROL p
NCIUEC'T/PNGINE'. LIC NO:
Ap FSS:
j
s -
CONTACT: PHONE:
PA,Y RAP )As (,
P44BUILDING
QTY. ELECTRIC PERM FEE
PERMIT INFO
BLDG CIJ?Cf� PLUM M
rL'�} xryl�
ery
PERMIT ISSUANCE i�
I—
LICENSED underMSDnsofna TION
Iherebyaffi ICENSE licensed uACTORvisiEC"RATION(commrncingwith
an R100)of Division 3 of the Businessund Profess' us Code, and my license is in
full force and effect.
j License Clasl Lit.p {O� J���,.�
pppl.lANCES- RPSIDF.NTIAL Ct �r
��� JOB DE$C P'fl /
•A'N` •A Q•Vw1<A6L
�/,•I
PANELS
UP'T02W AMPS
201 - 1000 AMPS
Date Conuactor J &*-ss
CIFfECTS DE LARATION
1 ' my s xh II be nseJ as public records.
cilia
` , ,fie
OVER TWO AMPS
SQ. FP. FLOOR AREA
$/SQ. IT.
SIGNS ELECTRICAL
Li used
SPECIAL CIRCUIT/MISC.
rionsolial
WNEN-BUILDER DECLARATION
I hereby affirm that I ran etentpt from the Cas License Lew for the
TEMP. MET 'CR OR POLE INST.
fallowing tuusan(Sectien]0]LS, business and Professionssions Code: Any city mentality
'
which requires n prnnil re conawa, ape, improve, demolish, any swcture
slicenamgalso the filoa signedatamment
forsuchCo
POWER DEVICES
that heor
u pursuant to the rovisi ns
Thalheis licensedp Sectio Ithe)of provisions of the Contractor's Lienulawns Coder
rosion's Limits, La
9(cammencing with Section 7f1007 of DivisinnJaf the Business And Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
.,but be is esentpt tbemfmmund the basis for the Alleged aminptinn. Any violation of
Section 9031.5 by any Applicvnfar. permit subjects tbeapPlicannn acivil penahy of
'� 6
NI Fps-SWITCIIGS-FIXTURES /
nor mora than five hundred dollars ($5110).
❑ I. as owner ofthe propeny, or my employees with wages as their solecompcmation,
/
NEW RESIDINTIALELECfR_SQ. FT.
S1 DRIES
'IYPECONSTRUCfION
will do the work, And the structure is not intended oroffrred for sale (Sec. 7W4, Business
and Profession Code: The Contractor's License Law does not Apply m Aa awner of
Araper, who builds or improves thcreon,and who doessuch work himselfor through his
own employees, provided Thalsuch intpravements are not late admofferedforsale. If,1.
RES. UNITS
1
however, the building or improvement is sold withinone year of completion, theowner-
builder will have the burden of proving that he did not build m improve for purpose of
1�
lL`�
QTY. PLUMBING PERMIT FEE
sale.).
❑ I,n awner ofthepropcnY.am cacluxiv<IYconwcting wiN licensed conwnan la
jet. D'
APN
onslranl Ilte project (Seo. 7tH4, Business and Profesaloni Code:) The Contractors
('
License Law does no, apply ran ownerofpropetty who buildaorimprov<s Nerean,and
PERMIT ISSUANCE
who contracts for such pmjecis with acoolraaor(s) licensed pnrscom'udi Commemr's
License Law.
ALTAR-ORAIN&VPNT-WATER (EA) assasts
rRESUMMARY
❑ I an intent, node Sec. , B & P C for his reason
BACK FLOW PROTECT. DEVICE
UTSI E iE5
Owner Dat°
DRAIN$ - FI.00RNOOFARP.A, CONT.
, ,
SANITARY YN
RF,CEIPTp
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a cenifial of consent o self-imum, or a cenificaeof
Workers' Compensation Insurance or a certified copy etmmm(See 3800, Lab CJ which
SCHOOLTAX YN
RECEIPT#
1 FIXTURES -PER TRAP
{ �
PARKFEB Y N
covers all employee's under this permit.
Policy M
RE.CEIPra
` GAS - PA. SYSTEM -1 INC.4OUTLETS
BUILDING DIVISION FEES
C0.0110-
GAS -EA. SYSTEM -OVER 4(EA)
PLANCI IECK FEE ��
NQf Ce tilled copy is hereby fumished.
miffed copy is filed with the city inspection division.
GREASUINDUSTRL WASTE INTERCEPTOR
GRADING FET?
CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPF'NSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FU
ENERGY FEE
(Thissectionneednot be completed ifNe penal is for one hundred dollsua ESIOE
or leas.)
WATER HEATER W/VENT/ELEM
I cervi fy that in the performance of the work for which this Permit is issued, l shall
nal employ any person in any manner so m to become subject to the Workers
Compcusaion Lawsof CAlifomiu, Data
Applicant
WATER SYSTEMTREATING
PAID
Dam Receipts
NOTICE TO APPLICANT:ILaflc, making this Cenifiemeof Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cade, you must
NEW RESIDENTIAL PLMB. SQ. FI'.
TOTAL:
forthwith comply with such provisions or this Knimi shall be deemed marked.
BUILDING FEE ,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm thin There is a construction lending agency for the fam oreanee of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
0 �a
ELECTRIC FEE
Lender's Address
QTY. MECHANICAL PERMIT PEE
PLUMBING FEE f�
1 certify that I have read this application and stateThat the above information is
comet. Iugrce to comply with all city unJ rounty nnlinuncesundxmmlawsrelatinglo
PERMITISSUANCE 1
MECHANICAL FEE
builmogemstruedon, and hereby ounhorix representatives ofthis city matter upon the
abovemantamed mpenyforinspectionpurysnes.
i
ALTF-RORADDTOMECIL
CONSTRUCTIONTAX
(We) og r save, Inde y and keep hnrmleaa the City of Cupertino against
liabilines,ju an'. costsa uses which ntayin any waysecomitia est said City
AIR HANDLING UNIT (TO 10,0(1() CFM7
In coal of the gran' (this permit.
AIR HANDLING UNIT (OVER I0,00) CFM)
Signature a- pylic VCo actor Dam
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT(TO I00.000 BTU)
fIA2lARDOUS MA'T'ERIALS DISCLOSURE
Date Formal#
Will the applicant or num building occupant store or handle haturdous material
as defined by the Cupertino Municipal Calc, Chapter 9.12, and the Ilealth and Safety
11 EATING UNIT (OVER IIXI,IIW BTU)
T L:
Code, Section 2 )9
Yes
0 Y',, ❑ No
VENTILATION FAN (SINGLE RESID)
Will the building use
BOILER -COMP OHP OR I W,000 BTU)
ISSUANCE DATE
air coicantnrfumm
by the
-0nmict? air contaminants as Acfined by the Huy Area Air Quality Management
AreaAen Quality Management
District?
BOILER - COMP(OVER IW,000BT H
Al ry yy
W
❑Yes ❑Nn
U
Jr,
NEWRESIDP.NTIAL MECIT. SQ. FI'.
1 have mad the hmnNous materials requircments under Chapter 6,95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534 1 understand that
- s- 619.
if the building does not yhave Aai that itis my responsibility to ratify the
occupant mine the requirmments nems whish must hi met prior to issuance of u Certificate of
M.,
rVk/rJ
Qcupuncy,
n.
ISSUED BY:
Owner or aahoritedagenl Dal
T /
OFFICE