24476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'1'RICA], PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL /1 �1 C
BUILDING DIVISION PROJF.CTIDEN'TIFICA'I[ON LFL V
HUII.DINGADDRISS: SANITARY NO, APPLICA'I ION SUBMITI'Al.DATE:
UNIT X LOT q
O NERS NAME: ^ PHOyY� /� C RA 'OR'S NA E: LIC NO'
,1 ` )C' / I —1` 1 NIC CONTROL p
�ARCHITBCI'/FNGINEER: LIC NO: ADDR S: ytY� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELF.CI'RIC PERMIT FEE
BLDG ELECT PLUMB @IRCII
P[RMIT ISSUANCE ❑ ❑ ❑ y�l
LICENSIiD CON'TRACTOR'S DFCLARA'1'ION APPLIANCES-RESIDEWIAL TOB UESCRIPI'TON
py�Z IM1ereby vffrtn thmlam licensed under provisions of Chapter9(commencing with ^ _ w
�i100 Section](100)of UiviainnJ ofthe Business and Professions Code,and my Ticenx is in PANELS 'w\ l�,'J//'s
(ti W C full force and eft
FZa, Live Ivs. Lic.X UP TO 400 AMPS
y6y DZ Contmcnn llkor 201-Rod AMPS
ZOZ)o` ARCHU EMS DECLARNII OVER IOW AMPS SQ.FIT,FLOOR AREA E/Sp.PE,
O Z—O I understand my plans shall be used as public records.
Fn
m SIGNS ELECTRICAL
gLicensed Profeaamrtm
Cyt1'Q Ot I it. Bempt from
mDECLARATION SPECIAL CIRCUIT/MISC,
06U 1 hereby affirm that 1 nm exempt from the Contractor's License Law for Oe
miliot+1LL�N which molmnxn(Switonconstrut.7031,5, sinessand
ove,deolih,or:Any city or county TEMP.METIER OR POLE INET'.
F❑- m which reyuims a Penni[is consnun,alter,improve,demolish,or repair any swnurc
Wr& o that
he iticensed,nlsoanniti th thevisios f the Co Permit Licele se].m statement POWIER DEVICES
� �0s 9(comisncing with Sumuotheprnfheisinf the Ce Businentractor ss
License oder
6ke4 9(commeisexemith Semina)sfruin and)he basision Joltheed exe sand Profusions Cod e) SWIMMING POOL IELECIAIC VALUATION
LRm onhat 7031. byanpt appliaut fornd a Permit vbjecisthe hgedexemptlnn. civiny l
of
FZ�' No none than
by any applicant apermi[eubjeda the applicmnoucivil penehy of OUTLIE'1'S-EWITCI TIES-FI%T'URIES
not marc than five hundred dollars(SSW). NEW RESIDE ELECT Sp.Il'.
h] `� ❑ I,asowncrofthopmKKty.ormyemployeeswiihwugesastheirsolecomlx^smian. STORIES TYPE.CONSTRUCf1ON
d will do Ne work.and the stracmrcis^m intended oroffered forsale(Sec.']044,Business
and Professions Cwle:The Contractor's License Law does no,apply m an hwner of
property who builds or impruves thereon,and who dres ouch wink himself m through his
employees,provided that such improvememsarenm imemeJaroffcred Thresh.If, I OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
huildcr will have the burden of proving that I¢did not build hr improve for purpose of
1e'1' QTY, PLUMBING PERMIT FEE FLOODZONE AIN
❑ Iuct the pr jest(S x.70,1, xdesis and Pr fessi g s Cndc:)'Me onto ata
construct the project(Sea oano Business and Professions Crimpmve Co n. is
Lice nae Lawdoesnmapo jects with
puorimpmvee Contracmd PERMIT ISSUANCE'
whence La trfnrsuch pmjecUwithncontrnemr(s)licensed puaumpe the Contractor's ALI IM MA) v
License Lew. 1 P.E SUMMARY
❑ I am exempt under Sec. B&P C for thix ream BACK FLOW PROTECT.DEVICE Iff.IDE IS
SANITARY Y N
Owner Date III PUTT X
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.CONE. SCHOOL TAX Y N
• Ihereby affinn[list l have a cenifrere of consentto self-Insure,ora certificate of RECEIPT#
cr%Compensa[ionlmurmceoracenifedcopy[hereof(Sm.3gW,Lab C.)whieb FIXTURES-PER TRAP PARK FEE Y N
croverni to u rtgypr�iv GAS-EA.SYSTEM-I INC. OUTLITS RECEIPT
Pol'syN YC • 'cJ BUILDING DIVISION FEES
Company 1 GAS-IA.SYSTEM OVER EA)
❑ Certified copy is hereby famished PLANCHECK FEE
rCenlflet]copy In riled with the city inspection division. GREASMNDUSTRL WAS'T'E INTERCEPTOR GRADING ITB
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
GTissection^eednot bccompined ifthepennit is Throne hundred dollars(5100) SEWER-SANITARY-STORM FA.2WFT. ENERGY THE
or less.)
I cenily that to not perfonnmme hf the work for which this permit is is l shall WATIER HEAT'E'R W/VENUVLECTR
not employ any person in any manner so as to become subject to Ne Workers' PAID
Grmpcas.1ka Lawaof Califomia. Dore WATER SYSi CM/I'RFATING Date Reedit#
p O Applicant
z7�-1 NOTICE.TO APPLICANT.If,aftermaking this Certificate hfRaemptioa,you should NEW RESIDENTIAL PLMB. SQ.FE TOTAL:
become snhjee[to the Workers Compensation provisions of the Lada Code,you must
? fonhwith comply with such provisions orchis permit shall be rimmed revoked. BUILDING FEE
VJ OCONSTRUCT ION LENDING AGENCY SPISMIC PER
1 hereby affirm that them is a coon tnrnum lending agency for the perfnrmmce of
the work for which this permit is issued(See3097,Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name
Q F Under's Address QTY. MECHANICAL PERMIT' NEE
PLUMBING PEE
L) I cenify that 1 have read this application and state that the above information is
correct.In above m comply with all cit deount ordinances and state laws nelatin to PER MIT ISSUANCI! /yam MF.CI IANICAL FEE
8 PYwi yon yon g 1/`/
.Fi y buildingeouswction,and hereby ao[horim representatives oft his city mercer upon the CONSTRUCfIONTAX
L) z above-mentioned pmpcny for inspection purposes. ALTER OR ADD I'O MECII.
(We)ugrm m save,indemnify and keep hormlua the City of Cupertino against
liabilities,judgments,cosrs and expenses which may in my way accmeamnst said City AIR HANDLING UNIT(TO 10,000 CFM)
qucnca oftha gmnan of 1 li 'email.
ATR HANDLING UNI'P(OVER 10.001)(7M)
S'mture of Applicant/CorwemrDnto EXHAUST HOOD(WMUCI)
PAID
HAZARDOUSMATERIA ISCLOSURE HEATING UNIT(TO I00,O00 BTU) Date _7eovjpq If
Will the applicant Or none building occupant some or handle harardmi,,norerivl HEAPING UNIT(OV M- 1100,00a,BI'U)
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
COAs.Sermon 25512(0)1
11 Yes ]0�/No VENTILATION FAN(SINGLE RESTD)
BOILER-COMP OHP OR I W,000 BTU) ISSUANCE DATE
Wasair
vcosencoments s building by the Bay equip menmuality Management ? A
• Disiner? air chntmninmta as define)by the Bey Area Air Quality Management BOIL ER-COMP(OVER 100,D)OBTU) V
Disricf! n
❑Yes No NEW RP.SIDENTIAI.MECII. SQ.IT, DEC 21��F
I have mad the hm Care,materials requirements under Chapter eras of the y
Cnlilismle Health&Eufay Cndo,Sations 23303,2333)and 25334. 1 undusamd[lint
if lhcbuilofthe m umcunendy havevrene Net it is issuance
of
[o notify the Y Ur (:(ll sJ
occ pan of the requirements whic must h met r or m issumc<of a Cenifcate of �j I V
O nc ratimarixdagem Dam 'TOTAL: ,1)O ISMIM)BY:
OFFICE