24770APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
I117D.Ia r. -ELECTRICAL
PERMITNO.
APPLICATION/PERMIT
PLUMBING-MECHANICAL
O
BUILDING SIGN
BUILDING PROJECTOWN't'llICA'TION
L
UILDING ADDRESS:
SANITARY NO.
AIPP�LI�CATh\O�N�SU//B��AfITTAL DA3T;
i%�
UNIT# LOT It
\�
WNtibia NAME::PHONE:
C NT ORS NAME LIC
NO:
NIC
❑
CONTROL It
5__
_'S f x L .mob
O
' ARCHITECI)ENGINEER: LIC NO: DDR S:
Oil /44 9,170 /�D �D ✓,
CONTACT: PHONE:
QTY, ELECTRIC PERMIT
FEE
BUILDING PIi INFO
NLD(i LIiCf PLUMB MF,CII
PLUM
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
IDB DESCRIPTION
mmcncing with
Ih7011
amlicensed undernd
Division Profession., Gale,and
Division3ofthe Business end PrnlessiOar Cade, nnJ my license is in
PANELS
I force anJ effect
I flumerandef
cense Class C—ls, I.ic.# S..SGn.jl
UI'T'0200AMPS
Dale Contrectnr
201 - IOW AMPS
ARCHITECTS I3F.CLARA'DON
I undemtund my plans shall bo used as public records.
OVER IBgIAMPS
/ \ gV�
A �Q.P O/R�9RL'AI N
' $'SQ. PT.
SIGNS ELECTRICAL
-�
U
E
Licensed Promasional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
Y R
I hereby that 1 oat exempt from the Conoannro License Lew for the
n. (Se am Code: Any city mcounty
regrcama(Section 7031.5, Business endue,
TEMP.METER OR MIX INST.
which requires a permit to de
tiller, improve, demolish, or mash any
Ils—
poor it) reportst a file usignW SWmmenl
prions statement
POWER DEVICES
licensede.alsorcgto me
that he is licensed pursuant m the provisions of the Comracash License Law (Chapter
IthemoriCrapracum'
�1
VALUATION
9(commumhtgwlih Section 7000) of DM,uon 3 of he Businose end Profeminns Cad e) SWIMMING POOL ELECTRIC
0nhal he is exempUllarefrom random basis for theullegcd exemption. Anyviwlatiwna(
7031.5 by any applicant for a permit subjects the applicant to a civil pealty nof
OUTLETS FIXTURES
not more than live hundred dollars ($50ro).
❑ wnenrftheproormyempindedorofwed
NEW RESIDENT IAL ELECTR _SQ. IT.
STORIES
'YPECONSTRUCTION
will d0lhesinas ande: structure 71 N4, Business
do forthe(Sim.c0m, Business
is
no Contractors License Lew Jas not apply t0 an owner of
Co License Low apply
and Professionsldsor
therecr's
pr who is
propmywhees,
own mprove aressuchwadhimulfenhroughhi.
ce i edthat suchcrimproven imp
proviimprovesth improvements
tne earrofdmofferul bursitis,IL
OCC, GROUP
RES, UNITS
illfin
ver.i l is sold eown
or
huilder purpose
TO
the burden ofemetnissathwithin dioneyew
builder will have the burden of proving that he did not build or improve for puryose of
illhav improve for f
sale.).
❑ I,uownerof the properly, entnxdusively mntmcling withlittnsedmnmctorstu
(jfY. PLUMBING PERMIT
FEE
FLOOD ZONE
APN
consumer the pmjcct (Sec. 7040 Business and Professions Coded The Conmcmr's
License Law does not apply loan owner ofpropeny whnbuil(isorimpmveslhereon,uml
PERMIT ISSUANCE
who commetsforsuchpmjccts with acommotor(s) Itceaud pursuant o the Contractor's
FEE SUMMARY
License Law. ALTER - DRAIN&VENT - WATER IRA)
❑ 1 =exempt under Sce, , B & PC for this reason
OUTSIDE FEL
BACK FLOW PROTECT. DEVICE
SANITARY Y -N
RECEIPT#
Owner -Dow-pRAINS
WORKMAN COMPENSATION DECLARATION
- FLOORROOI',AREA, GOND.
,
SCHOOLTAX YN
I ❑ Ihemby affirm thatlhuveacenificme afconsenno eelGinsurc, ora anificam of
FlXTUR[S - PER TRAP
RECEIPTM
PAMPER Y N
WnrkerA Compensntinn lneurunww nruanifiul copy therud(Sew.3g00, Leb CJ which
covers all employee's ander this p .i,.
GAS - EA. SYSTEM -1 INCA OUTLETS
RECEIPT N
BUILDING DIVISION FEES
Policy p
Company
GAS - EA. SYSTEM -OVER 4IRA)
P ANCHECK FEE
❑ Codified copy ishereby furnished.
GRADING FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OIs EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY PER
(Thissection neadnm becompleted ifthepmmitis foronehundmddollarri SEWER - SANITARY - STORM EA. 20DFT.
wriest.)
I cenify that in the performance of the work for which this permit is issued, l shall WATER IIFATER W/VENT/ELECTR
not employ any person in any moaner so as to become subject to the Workers
PAID
Cwmpensmion Lawsof Celifnmia. Date
WATER SYSTEM/IREATING
Data Receipt Is
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. PI'.
TOTAL:
became subject to the Workees Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or this permit shall he deemed revoked
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
ELECTRIC FEE
the walk for which this permit is is sued(Sec . 3097, Civ. C.) TOTAL:
Lender',, Name
Lendel'a Address
QTY. MECHANICALPI3RMIT
FEE
PLUMBING PER
1 certify that 1 have mad this application and scam that the above infurmetian is
rrcn. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buitdingconswction, and hereby authorise repressmatives of thiscity to enter upon the
CONSTRUCTION TAX
alswementioned propery for inspection purposes. I ALTER OR ADD TO MECIL
(We) agree to save, indemnify and keep harmless the City id Cupertino against
liabilities,juAgmems, costsundexpemx which may in my wayaccmeegaivt said City
AIR HANDLING UNIT (TO I0,000 CFM)
in romwqua fthc ting of Ibis pemsit.
eo
AIR HANDLING UNI9'(OVER I(I,gXI CPM)
SignatumCnntrflor Doe EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT nD Hal" PTU)
Date Raeipt It
Will the applicant or future building occupwn store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
HEATING UNIT 100,0(d) BTU)
TOTAL:
Cuda Section 25532(u)7
11 Yes EI No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
Will thcepplicamorfnturc building 0ecupam use equipnemorAeviccawhich emit
BOILER - COME CHP OR 100,000 BTU)
Incautious air contaminants n defined by the Bay Area Air Quality Mmagelnenl trict
Dither?
BOILER- COMP(OVER 100,0M BTU)
9,411)i ,
❑Yea 13 No
NEW RESIDENTIAL MliCll. SQ.IT.
/�
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Sufery Code, Sections 25505, 25533 mal 25534. 1 understand that
FED 11 1905
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must he met prior m issuance of a Certificate (if
C 1�
Occupancy.
L)
ISSUED BY:
Owner or uuNoriznl agent Dun, TOTAL:
OFFICE