24828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C ITY OF CUPERTINO R ILUIM1.-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n �I O 2 Q
BUILDING PROJECT IVENTIFTCATION L L�o CJ
BUILDING ADDRESS: k_y p /s//�//� SANITARY NO, APPLICATION SUBMITTAL DA'11
22364 Rl rV�� s%oma UNIT# LOT 5 t r` f ^
WNERS NAME:Hr 4ON0 N`y 70 ONTRACfOR'SN : LC (JLC„J/� N/C CONTROL
CHITF.CT/ENGINEER: �J LIC NO: J .DDRFSS:1-7`Z-1 � �G a_` ❑
corrrAcr: PHONE: QTY. EL LMICPERMIT - C, /�lC^L BUILDING PERMIT INFO -
BLDG ELECT PLUM MECH
PERMIT ISSUANCE SICY
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L�
JOB DESCRIPTION
OCZ hereby ofumthatl 3 orth Bu under provisifesion Code,and
(commencing se with
SCO S«tion70001 o(Division 3ol the Business arW Profession Cale,anJ my license is in PANELS sinsrob
y (—
License
C1...ellen. p
VCJ � .� / I7 ZO UPT02WAMPS �
G Z W Liccnm Class Cm M
r,z D �.CmnTSD 201-1000 AMPS
ZpNZ IIITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.IT.
ZZ_ l undenand my plans shall be used as public records. OVER IIXq AMPS
—
Z-1 SIGNS ELECTRICAL
<-2, Licensed Prulessional
y=Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
zz�
i OyU I hereby affirm Thal 1 am exempt from the Contractors License Law far the
Iia Oui following record.(Section 7031.5,Business and Profusions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any smucort
`e�Yito its issuance,also the applicant for such no file a signedstatement POWER DEVICES
Actor quires pp Permit Lo
jrGCp .that he is licensed pursuant the provisions of the Comracm/s License Law(Chapter SWIMMING POOL ELECTRIC
a-a_e' 9(commencing with Section 7")of Division 3 ufthe Business and Professions Cade) VALUAT6g ii
ots' or he is exempt therefrom and the basis for the allegedAn I t f C��
!='rn p ge Any IC OUTLETS-SWITCHES-FIXTURES Z SO�
I-Z a Second 7031.5 by any appiicant for a permitaubjects the applicem n..civil penalty of
not momthan five hundred do][.(SSW). NEW RESIDENTIAL ELECTR S PT.
CTI
KFa ❑ I,mownerofthe property,ormycmPloyeeawith wagamtheirsolecompensution, Q STORIES TYPE CONSTRUOT
a3= will Bothe work,and the he Cameroon's
imendese La a does
Sec.70 M.Business
pro erofasiona Cade:The Convect.'.License Taw rush
ea apply m an owner of
ownerywhobuilds.improvethimp andwhodoensuchworkoroffinedWande.Is (� HH 11
owneer.tim es,p building
or thauuchimprovemcnuartne esonfdordffon,forthe Owner. � _ �Y�S�UNITS
however.theavetn burden ovrmrm ishalteWinot build of cmpowefr purooe of O' V, IUJ K
builder wtll hove the burden rf proving that hr did nm build or improve for Dugwrse of
sa❑IaLl,asownerof the propcny,am exclusively conranin8 with licensed convacmrsm Q7' - PLUMBINGPERMIT `I( FEE TE APN
oocon the project(Sec.7043,Business and Professions Code:)The Cmnrucmr's PERMIT ISSUANCE
License Law does not apply to an owner of proprmy who budds or improva tenon,and
whoconnon,fmsuch Projects with a contmcianl licensed pursuantto the Comustars ALTER (EA) '. '
License Law. FEE SUMMARY
❑ 1 am exempt under Sec ,B dk P C for Nis maven BACK FLOW PROTECT.DEVICE OUTS F -T_
SANITARY YN_
Owner Duro DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a cerificate dfconaern to self-imaum,or a certificate of FIXTURES-PER TRAP RECEIPT
orken'Compemmon formance ora certified copy thereal 380.Lib C.)which PARK FEE Y_N_
coven all employees under permit. d GAS-FA.SYSTEM. INC.a OUTLETS
RECEIPT p
Policy M .Y BUILDING DIVISION FEES
Company I GAS-EA.SYSTEM-OVER 4(Eii) PLANCHECK FEE IV
❑ Certified copy is hereby fumished.
❑ Certified copy is fled with the city inspection division. GREASEgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is formic hundred dollar,(SIM) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit isismed,I shall WATER HEATER W/VENT/F.LECTR
nor employ any person in any manner so m to become subject to Ne WorkerPAID
Cma,matimn Lawsof California. Date WATER SYSTEMOREATING Dam Rrcelptg
Z Applicant
Z 2 NOTICE TO APPLICANT.If.after making this Certificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L4 become subject the Workers Compensation provisions of the Labor Code.you must
z
>_ fmNwith comply with such provisions or Nis permit shall be chmmed revoked, BUILDING HE �
1 [� CONSTRUCTION LENDING AGENCY( SEISMIC FEE
=) Z Ihereby off=that hem is a convection lending agency for Ne performance of
VJ the work for which this permit is issued(Sat.7097,Civ.C.) O AL: ELECTRIC FEE `
Lenders Name - .t"a "' "- a 1" rI ,\ �, t PLUMBING FEE
0 F Lenders Add.. QTY. `f',:-"'',° MECHANICAL PERMIT',— IF""Is 'c4'FBE�tt- f
> 1 certify that 1 have read this application and state that the above information is -
�"' correct.I agree m comply with all city and county ordinances and stat laws mining to PERMITISSUANCE MECHANICAL FEE
D' building convection.and hereby moonrise refacramtiver of this city to enter upon the
Z Arynnaemioned pec CONSTRUCTIONTAX
V z p save, nd ins tion keepuxs. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep my
the Ciryco Cupertino against
liabilitiesuence costs fpenses which mayinany way eccmeogeinst said City AIR HANDLING UNIT TO 10.0011CFM)
in consequence of the grantingof this pe a _ AIR HANDLING UNIT(OVER I.UMICFM) L_
EXHAUST HOOD Signature of ApplicanUComr� r Dae PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNITfTO 100.000 BTU) Data
Rec 1pt
Will the applicant or future building Occupant note or handle hazardous material HEATING UNIT(OVER IIK1.(Hxl BTU) IOTA
as defined by the Cuprnino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532fal,' VENTILATION FAN(SINGLE REM
❑Yes ❑No
ISSUANCE DATE
Wilhheapplicanmrfuture buiIdling acup:muse equipment ardevices which emit BOILER-COMP CUP OR IfX4UA)BTU)
alliWaseardsom air contaminants as defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER 1011,000 BTU)
qW imict7 A 9
❑Yea ❑No NEW RESIDENTIAL MECI1. SQ.FT.
.._ I have orad the hazvdnms materials requirements under Chapter 6,95 of the REAR - 3 199
California[health&$,(ay Cale,Sonimns 25505.25533 and 25530. 1 understand that
if the building does not cur ofiv have a moam.(hut it is my mmantsibility to notify the
occupant dl the requirements which rouw be met poor or issuance of o Cmiticme cot fill is
Occupancy.
Owner nr autho ind.gem Dam TOTAL: ISSUED BY:
OFFICE