24720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL DING-ELBC FRICAL PERMITNO. ^ ^1 O
APPLICATION/PERMIT' PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION L
BUILDING ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
a uNrrw LOT
OWNER NAM,: PITONE: CONTRACfOR'SN ME: LIC NO'.
f, NEC CONTROL#
1RCI T /EN IN..R: LTC NO: ^ - ADDRESS: ❑
/ i C
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG LEC( PLUMB MEE
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. - TOB DESC ION
Mzz Thereby affirm that l an licensed underpervoroaraof Chaprer9(commencing with
�WCO Section 7000)of Division 3 of the Business and Professions Co de,andmylice..ssisin PANELS t
y� t I If and eft'ct. q
4E'zTd License Class Lic.w J_//}.�/J/`� LL��.. �� UP TO 200 AMPS
m Qy Date Compi ler Xf 4 A /F.q¢(P Qi. 201-IOW AMPS
ZONZ� ARCHITECT'S DECLARATION OVER INTO AMPS SQ.FT.FLOOR AREA $/SQ.PC
O z aFq., I understand my plans shall be used a public records.
rex2,J SIGNS ELECTRICAL
qq'' 8. Licensed Prof..ional
d� U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
k O y I herehy affirm Wat 1 am exempt from Lha C.ppecom s License Law for the
W�Oon folluwirrincroa(Senlon 0031.5.Business and Professions Code:Any city.,county TEMP.METER OR POLE INSI
w 'a which requires a permit to conslrvcl,alter,improve,demolish nr repair any snuewre '1
3 1¢7 primmit,issuance,alsorequires@eupplimptfofsu chpemriItoEbT_ignedsmTement POWER DEVICES I� f .✓ { V h
Q O That he is liecneod puma.,to the p...ideas or(he Comrnc er's Llcooso Law(Chapter 4 J
L e� 9Tempor acing with Section 7000).YDivision 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC /5 VAL ATION
or that he is exempt Therefrom and the basis for the alleged exemption.Any viol......of OUTLETS-SWITCHES-FI%T ES �(1/��_]
F C Section 9031.5 by any applicant for o permit subjects her app,Icam to.aivi l penalty of
I more than live hundred dollars($500). NEW RESIDENTIAL HLP.CI'R S FT.
mW p n❑ l,asownernf lheprnperty,onnyemployeeswilh wugcsastheirsole c.mpensntion, Q' STORIES 'TYPE CONSTRUCTION
p, will do the work,and lhealrnewm is not imendedmeffered failure(Sec.9044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property wh.buildsorimpmvestheteon,and whod.es such w.rkhimaelf.Ithr.ugh his
own employers,provided thatsuch lmprochappleare not intended.,offend foraule.If, OCC GROUP RES.UNITS
o
however,the building orimprovement is sold within one yearofcompletiou,diewner- TOTAL:
builder will have the huNen of proving that he did not build or improve for purpose of
sale.). m+8rr - -
❑ Las ownernflhe property,an exclusivelycnnnuding with licensed contractorsto QTY: x j j ,PLUMBING PERMIT � FEE PLOOD ZONE APN
construct The project(Sec.70,14,Business and Professions Code:)The Coutmmov's
License Law d.nanm apply to an lovesa fpr.perty wbohuildeorimproves thereon,and PERMIT ISSUANCE
who contracts l'orsuch projects with ac.ntmetor(s)licensed pursuam to the Conlmctole ALTER License Law. (13A) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y N
Owner Date DRAINS FLOOR,ROOF,ARCA,CONI. RECEIPT#
-
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherebyaffirmlhatlhaveacenificae.fc.nsem to self-insure,nrecertificae of FIXTURES-PER TRAP RECEIPT..
Wmkers'Croup wstried Insurance or oaenificl copy Named(Ser.3500,Lot,C.)which PARK FEB Y N
cravers employee's nderthix permit. RECEIPT..
Policy X /7U/O GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Company_/1[ ¢: �_p,f� GAS-EA.SYSTEM-OVER 4BEAT PLANCHECK PEE
❑ Cenlfied copy is herehy furnished.
Pr Certified ,,,is filed avahthe city inspection division. GREASE/INDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE Oh EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(this section need sol he completed iffie permit is forone hundred dollas($IN) SEWER-SANITARY-STORM EA.200M. ENERGY FEE
or less.)
I certifythal in theperfermanceofthe work for which This permit is issued,[shall WATER HEATER W/VENLELECTR
not employ any person in any manner so es t.become subject to the Workers' PAID
Colmoreatoo Lawsof California. Dam _ WATER SYSTEWREATING
Date RecclplN
C) Z Applmma
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff.
F .�-T hec.maobject to the Wmkers Compensation provisions of the Labor Code,you most
t'OTAL:
� , forthwith comply with such prolan.,or this pnroit shall be deemed revoked. BUILDINE�E
OCONSTRUCTION LENDING AGENCY SEISMIC Iherehyaffirmis Per it isisued(Six.3lending agency for the performwce of
the work for..Lich Ihls permit is IssueB(Sec.J097,Civ.C.) TOTAL: ELECTRILendef.NameL.eade Add eas QTY.,` �"MECHANICALPERMIT � FEBPLUMBI1 pity that 1 have read rias application and.state that The above mformebonowe".Iogree m comply with ell airy and c.untyoNinare.and state laws mlednIT PERMIT ISSUANCE MECHAN
C4 building cons,...tion,andhereby nuthnce,repmsenlmivesoftlas city to enter upon the
V 'y above mentioned property CONSTRUCTION TAX
for inspection purposes. ALTER OR ADD TO MF.CH.
r�77 (We)agree to save,indemnify and keep harmless the City of Cupertino against
Ilabllltles,Judgmenl Nandaxpatses which maynarywayaogamm,ai<City AIR HANDLING UNIT(TO BLOW CPM)
at r equence@ heg at is of this it. mue 2�t( vs
7 AIR HANDLING UNIT(OVER 10.000 CPM)
' Si m of ApplicansContracmr Dale EXHAUST HOOD(W/DUCT)
' - =R-c
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU)
Will the applicant or future building occupant store or handle hazardous material BEATING UNIT(OVER IOO,WO ITT U)as defined by the C
upertino Municipal Code.Chapter 9.12,and the Health and SafetyCode,9cclinn 25532()! ��ee,, VENTILATION FAN(SINGLE RESID)❑Yes qNn
Will the atanamor(mare building by themuse Ams Air Q deviceswhichemit
BOILER-COME(JOE OR 100,000 BTU) ISSUANCE DATE
hazardous air c...taminanre ase defined by the Bey Aree Air Quality Management BOILER-COME(OVER 100,100 BTU) PAID A I D
DindmY Y' M V 6J
13 Yes �No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials requirements undo Chapter 6.95 d the AUG
/1n �^^^
Curebuil Hwlth&1.1ra Cully have m...05,25533 and 255J4. IundernanJ shat UG 993
if the building does not currently have a tenant,tbel it is my responsibility to notify the �r
ccupam of the requimmems which must be mat prior to issuonw of a CcrdOcum of Cf l l I
Oacupuney. y
Owner or authorized agent Date L: ISSUED BY:
OFFICE