24688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
WOWNERS3WE:
OFERTINO BUILDING-ELECTRICAL PERMITNO
ISION APPLICATION/PERMIT PING PROJECT
MFICHANIFIC 24688
nuu.DlNc rxodlec'r Im:rvrlxx:n'ru1N
ADDRESS / SANITARY NO. APPLICATION SUBMITTAL DATE
�7 UNIT4 LOT#/ PHONE: CONTR OR'S NAME O l /Q� Ni CONTROLM
F.CHITE /EN INELR: 'V LIC NO: ADDR; S: Z� ( O ❑
CONTACT: PHONE: J
QTY. ELECTRIC PERMIT' PEE BUILDING PERMIT INFO
BB 0 HLECf P UMB MECH
PERMIT ISSUANCE /s
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
G C50 e")ofrmthmlam of Til sed Business
add rioneions Coder and(commencing with � �
FOO emion]U(q)of Division me Buxiness and Professions Cale,and mylicensc is in PANELS
y�U fall fnrceimd effect.
License Class LicX UP'I'0200 AMPS
y« hate Com maor 201-I"AMPS
ZUK ARCHITECT'S DECLARATION OVER I"AMPS 1 �Sp.I'CpLOpg,9Rlj� ak {ISQ. I'.
OZ-0 lundentnnd my plans sbellhumcdss public rccoNs. /(�\ `„ I' II lyl`V,
FyFW SIGNS ELECTRICAL. \ f
�W�¢ Licensed lhofessional OWNER.RUIFDER DECLARATION SPECIAL CIRCUTOMISC. 1I LP U u E
i�0a(V. 1 hereby affirm that L ma exempt from the Contractors License Law for the �/ Illl
m3 ul following reason.(Section 7031.5.Business and Prolessian Code:Any city or stony TEMP.METER OR POLL INST.
F=FS�g bicbregairripmmilwroustruct,alter,intpmvedram iah,mmimranymucturc
K�Q� prior mils issuance.also respires the applicant fortiori perinl0r fileasigned smemem POWER DEVICES AT
tymAO tam he is licensed animunuo the Provisions of the Contractors License Law(Chnprer SWIMMING POOL ELECTRIC
L 9(rnmmcncing with Section 700()of Division Jofthe Business and Prrfessirns Case) VALUA'I'IOAL
iQmN ,,but he is exempt ahenfrearma he basis(onicalleged exemption.Any sadmionof OUTLETS-SWITCIIIS-FU(TURPS DD / ` (270
�Z< Section 7031.5 by any applicant(or a permit subjects the upplicmnracivil peachy of
not marc than rise hundred dol)ara(3500).
N`L'p ❑ Lusownem(theproperty,urmyempinyeee with wugeses iheirso ecompensmioo, NEW RISLDIBdT1AL ELIiCTR _SQ.F STORIES TYPE CONSTRUCT ION
L3� will Bothe work,andthc swcture is not iatcndeJmOffered for ade(Sec.7044,Business
and Professions Code:The Crnuaaor's License Law docs not apply,.as owner of
property who builds or improves thereon,and who docs such work himealfor through his -
employeea,provided that such improvemetnsare not inteadecoroffcred foraale.If. OCC.GROUP RES.UNITS
however,lhebuildingorimprovement is sold wiffimone yearnfwm,itumaiheowner-
builder will have the burden of proving that he did not build or improve An purpose of
sated.
❑ I,asownerofthepropcny,amexclusivelycomrnetingwiihlicenudconttacmmto QTY. PLUMBING PERMIT FCC FLOODZONF. APN
nswct the project(Sec.7044,Business and Professions Cade:)The Conmamor's
License Law does nnlapply waauwarrol'pr.Illy whmlamidaorimproves them oland PERMIT ISSUANCE aii'.
who tortoni forsuch projects with acontractotfa)licensed pursuant to the Connuctor's
License Law. ALTER-DRAIN&VENT-WATER B-A) - FEESUMMARY
❑ I em exempt under Sea N&P C for chis reason BACK FLOW PRO'll?CT.DEVICE OUTSIDE FVa
SANITARY Y N
Owner Data DRAINS-PLOORROOPAREACOND. RECEIPT#
, , . .
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
❑ I hereby affirm that l have acenificnn adornment toself-asure,macerfifcalcof FIXTURES PER TRAP RECF.IFI'#
'Wineri Cmuncoaatic hionaemn certified copymercof(Sec 1800,LaFC.)which PARK FEE Y_N
covers all employee's under Bids permit. GAS-PA.SYSTEM.I INC.4 OLD LETS RECEUvr#
Policy# BUILDING DIVISION FFE S
Cam ny OAS-EA.SYST1l OVFR4(EA) PLANCHECI i
edified copy is hereby fumisi
❑ Certified copy is fled with the city lnspaiion division. GREASE/INDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This senior ruefint M completed ifibe permit is force hundred dollars($100) SEWER-SANITARY-STORM EA.2001 ENERGY FLIP
or Inst.)
I cavity that in the perfarmance of the work for which this Permit is issued,i shall WATER HEA]'ER W/VENT/FiLLCTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsr(Califomia. Ucte WATER SYSTEM/BEATING Data RecrinN
O z Applicant
z � NOTICE TO APPLICAN'T:If,alterntakingibi,Certificate ofExemption,you hold NEW RESIDBil PLMIL—SQ.FT. TOTAL:
t+ � become subject to the Workers Compensation previsions ofthe Labor Cade,you must
t� 7 forthwith comply with such provisions or this permit shull be deemed revoked. BUILDING FEE
OWa Q CONSTRUCTION LENDING AGENCY SEISMIC Fu
Uz I hereby aftinothm there isa construction lendingagency for the perfurmimce of
O the work for which this Permit is issued(Sec.3097,Civ,C.) ELECTRIC FEEV. �#
Lender's Name
0 r. Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V T mnify that I have read this application and stem but Ne above information is MECHANICAL FEE correct.lagrtt In complywithullcily enJcauntynrdinunca nnJ smteluwa relatingio PERMIT ISSUANCE
building emminti ion,nnd hereby umhodaerepresentativesofthia city,.emerupon the CONSTRUCTION TAX
V 7 above mentioned properly for inspection purposes, ALIP.RORADDTOMECH.
G7 (We)agree m eve,indemnify and keep harmless the City of CuPenirm against
liubilitics,ju cam,costs andexpenses whichtocsinany way accmesgainst said City AIR HANDLING UNIT(TO ULDIM CFM)
in consegr of the granting of ' AIR L JANGLING UNIT(OVER 10.00 CFM))
60195
Sig m Appliwnt/ConrmTo, Data EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MA'T'ERIALS DISCLOSURE or handle
I IfLTINO UNIT TO 100,00(1 BTU) Date Recript#
Will the appratania.future icipal oade,Cmg occupant srne2,innate hHealth ,.Safety HEATING ON IT(OVER 100,000 NT U) TOTAL:
ea defined by the Cupertino Municipal Code,Chapter 9.12,and the Health wd Safety
Cele.Section 25532(u)9
C3 Yea ❑No VEN'HLA'1'ION PAN(SINGLE RESID)
F It
Will the applicant or fu,.mhuildingrv;cupanl usecyuipmem nrdevices whichemit
BOILER-COMP(JHPOR 100,00013TU) ISSUANCE U JE
hssardnua air contaminants as defined by the Bay Ana Air Quality Management BOILER-COMP(OVER 100,0001HU)
District?
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.14. f(� O 1(�(I�
1 have tool the hamat
rdous merials rcquiremmos under Chapter 6.95 of the FI IJJ
California Health&Safety Code,Sections 25505,25533 and 25534. l understand that C�I Y Ur �1 t - I U
if the building does not currently have a tenant,that it is my responsibility to ratify the �'��.(itly Uri S
occupant of the requirements which must he met prior to issuance of a Cenificat,of —' a'J
Occupancy.
Owner rr authorized agent Dam TOTAL: ISSUED BY:
OFFICE