24542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC1 RIUAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 24542
BUILIINGADDRESS: SANITARY NO. APIIAGTIONSUBMITTALDATH
l : Po W �r UNITM LOTH h -L qt.G,
OWNERS NAME: P CONTRAC'TOR'S NAME: LIC NO:
NIC CON'I'ROLN
•ARCI 1;Cf/HNGfNEE LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF.
BLDG ELECT PLUMB MEC11
PERMIT ISSUANCES El E] El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 108 OFSC0.IPTION
Metz I hereby affirmthat l amliceaxd under provisiomrof Chapters)(commencing with
WOO fall(.nefcandefllivirinnJnf the Business and Rofessiona Code,end my license is in PANELS
t W{'' Section 7").fect.
UA License Class Lid.M UPT0200AMP5
m6vai Das Contmnor OIOW AMPS �� I
zOiaOVER
z� ARCHITECTS DECLARATION SQ R A f/ .FT.
1 understand my plans shell he uuJ as puhlic rccerdr. OVER TUBO AMPS
O z^ SIGNS ELECTRICAL
Licensed ProfessionalT E
C OWNER-cxem,,ERDF.CLARATIme SPECIAL CIRCUIT/MISC. v
W "t 1 hereby u.(Se that 1 am exempt fourths,Conuacmrs License 1<w for the
�'3ay following rcusoa(Scmion70]LS,Business and Profusions Code:Any city or county TEMP.METER OR POLF.INST.
,� which requires a perm,to emomea t,almr,improve,demolish,or repair,any swnure TE
Y7 prior to its issmam,also requira the applicant for such permit to file a signed statement POWER DEVICES
a'a O that he is licensed pursuant o the provisions of the Commences License Law(Chapter _
Pc 9(Bammencing with Section 70000o1'Division7ofthe Bminua and Professions Code) SWIMMING POOL ELISCT'RIC VALUA9'1^w-�
XW2rn or that he is exempttherefrom and the basis for Be alleged exemption.Any violation of �tl
tz< Section 7071.5 by any applicant fear.permil mi jean the upplicsnt ma civil penalty of OUTLETS-SWITCHES-FIXTURES
not more Chun Eve hundred dollars(E500). NEW RESIDENTIAL ELECHt _SQ.FT.
O STORIES TYPE CONSTRUCTION
tCem ❑ .theavne,tarri pmpmy,et....Iunoyeeswithwegesulhei(site cam,Business
a will do Professions
andel: structure ecce is License
Law
do s not apply to an Business
pandro Professions Cade:The Contractor's License Inw does not apply row owner of
propmywyees,provided
maxonlhemprove whadersuchdidedomxBor for
side.
OCC.GROUP RES.UNITS
own employees,providedmproverch impmvatn within a yeadecompleered female. r-
however thebuildingor improvement is sold within one yeman improve
m rove far the mse of
builder will have the burden of n that he Jitl net build or im rove for f TOTAL"
pmvi g p purpuseo
ale.).
[JLusownaom
fthe property, exclusively m
ycomracting with contmnom QTY. PLUMBING PERMIT FEE FLOOD_ZONE APN
construct the project(Sec.7044,Business and Professions Code:)no Contmumrn PERMIT ISSUANCE
License Law does not apply m on owner of property who milds m improves thcrcon,and
who contracts forsuch pormiswith a controdurr s)licensed pursuant mthe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um exempt under Se. D&P C Im tM1is ruse BACK FLOW PROTECT.DEVICE DID S )'I'P,s6
SANITARY YN
Owner Date RF.CI?IPT M
DRAINS,FLOOR,ROOF,ARG4 CONO.
WORKMAN COMPENSATION SCHOOL T'AX Y N
❑ Ihertby uffimtthatl have acenificam of cnnsem to xll'insure,mucertificutc of
FIXTURES-PERI'RAP RECEIPTg
Workere'Cnm,ensmion lnsumncenracenifeJ copy thereof(Sec.]g00,lun C.)which PARK FEE Y N
coven all employees under this permit. GAS-G.SYSTEM-1 INC.4 OUTLETS RF.CCIPT g
.Policy k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnisher.
❑ Cmilicd cosy is tiled with the city inspersion division. GREASE/INDUSTILLWASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMP17NSATION INSURANCE
Tis etitiamed not be completed ifthe permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m IevJ
I twin fy that i n theperformance of the work for which this permit is issued.I shut WATER HEATER W/VENT/ELECTR
not employ any perso in my manner so as m become subjec Moshe Woflums PAID
mpenxrion ea d em a 1'L 1.�N1- WATER SYSTEMTREATING Data Reeipttl
o o"hoor- ; i
z OTICE TO Al 1,1,jr ANT:IL after making thi Certificate of F.xcmption,you should NEWRESIDENTIALPLMB. SQ.Fit". TOTAL:
become subject to the Workers Compensation provisions of the Labor Code,you most
a , forthwith mmplywith such provisions or this permit shallbedeemed revoked. BUILIIINGFEIS rL
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that there is a construction lending agency for the performance of
O Ne work for which this permit is issued(Sec.7097,Civ.C.) TOTAL: ELECTRIC FEE
Leadefa Nome
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I cmity that 1 have mad this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MSCI IANICAL FEE
VI"' y building construction,and hereby uudemin represenmtives of this city to corer upon Ne CONSTRUCTION TAX
7 atwvememioned property for inspection purposes. ALTER OR ADD TO MECH.
�-r (We)agree m save,indemnify and keep Iwmdcsa the City of Catania.agaimt
liabilities,Judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(10 10.000 CPM)
in consequence of the grunting of Chir permit.
WAIR HANDLING UNIT(OVER 10'"CPM)
< L
'-gnat o ApplicuaUComracmr Out. EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BIU) Date Receipt#
Will the applicant or future building occupant&rare or handle Itasmdnm material
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNH'(OVER 100,000 BTU) TOTAL:
Code,Section 25512(x)?
❑Yes ❑No VENTILATION FAN(SINGLE RISIU)
BOILER-COMP(]I IP OR 100,00)BTU) ISSUANCE DATE
Will theepplicant orfmurc buildingmeupantuxequipmem ordevicu whichemit � p B
harmonious air examinations as defined by the Bay Area Air Quality Matagtmtln BOILER-COMP(OVER IOO,(M BTU) Po
Dlstrict7 III
❑Yes 1:1 No NF.W RISIDEN'I'IAL MliCll. SQ.FT. ^BEC 2
1 have read the haaardam materials requirements under Chapter 6.95 of the 1
992
California lk-kh&Safety Cade,Sections 25505,255]]and 25534. 1 understood-bet
ifthelooding docs not currently have a tenant,that it is my responsibility to notify the �I1 Ur C;Ijl e ere
eecupent of the requirminc ns which must be met prior to issuance of a Circulate of //��//yV��
Occupancy. _� V
Owner or amhotiud agcm Dom TOTAL: ISSUED RY:
OFFICE