24806 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILUINC.-ELEC MECH MECHANICAL PERMIT NO. 24806
� /� 8 O 6
APPLICATION/PERMIT PING PROJECTIDIANIFIC L4
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
IILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNI'TN LOTH
3- t-q3
(WNERS NAME: P ONE: CONTRACIOR'S NAML: LIC NO'.
1 ` , ✓• C. Lam; N/C CONTROL If
�ARCEIITCT GINEER: IC NO: ADDRESS: l:. — ❑
Tic t
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
L� 'LECT PLUMB MEC
PERMIT ISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION PERMI ISSUCES RESIDENTIAL L ESCR11'TION
Ms I hereby affirm that l am licensed under provisions of Chapmr9(commencing w'nM1
[iJ _ Section]0(q)of Division3of the Business and Professions Cuk,and my lirenu is in PANELS 2r1
U F full force unJ effect. .•(J 1 j( ��").P'n��
F,Zw License UPT02W AMPS • 1 `
y=y Lade Cnntmnor L�111J 201-1000 AMPS
?_Oy? A CHITECI'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
b Z_ I undersand my plans shall be used as public wants.
SIGNS ELECTRICAL
Licensed Professional
KW Wai OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
OWU�4 W E- 1 hereby affirm that 1 oto exempt from the Contractors License Law for the
u1'+0¢ following rcuson.(Scdion]03LS,business and Professions Code:Any city or county TEMP METER OR POLE INST. 1
ru. j which requite a permit to conswa•alter,improve,demolish,of repair any swcmm
f Y7 prior to its issuance,almr man theapplicam for such permit a file a signalsaament POWER DEVICES
ty Op 'hoe M1e is licensed pursmnuotM1e provisions of the Convamors License law(Chapar
°•o. K ') th Section SWIMMING POOL ELF.CIRIC
X.W (commencing wl )of Division3ofthe Business and Rofcssioos Cudc) ^ VALUATI0�y��\
Iy'^y mthat heisexempt
any
for
boxpermit
us the
to Aivil Penalty of OUTLETS-SWITCHES-FIXTURES ��
F-ZQ out po]03 LS by any upplicam forapermit wbjxls the applicanuoacivil penalty of
�'p rnmorc'Into five hundred dollars($5W).
o n❑ I.asownarofthcproperty.ormyemployeeswiNwagesaetheirselecompensation, NEW RFSIDEN'I'IAL ELECIR _$Q.FT. STORIES TYPGCONSTRUCTION
ad
will do the work,and ihestrucwre is not Emendedoroffend fofvlc(Sa9044.Business
and Professions Cade The Contractor's License law does not apply a ua owner of
property who builds nrimpowes Nercon,and whodms such work hinewifladim.gh his
employees,pmvid thatsuchimpmvcmcnzv notintendedmoffemdforsde.If.
OCC GROUP' RES.UNITS
however,the buildingor improvement is sold within one ycdofcompletion,the owner- TO
hudder wdl have the burden of proving @u'he did not build or improve Iia purpose of L
role.).
❑ L as ownermthe property,amexclusivelycommning with licrnsedconuacmrnm QTY. PLUMBING PERMIT• FEE FLOODZONIi APN
I'instruct the Project(Sec.7614,Business and Professions Code.)The Contractor's
icense Lnwdoes not upplyman ownensf propcny whubuildsorimprovea thereon.and PERMITISSUANCE19
whocommctsforsuchprojectswiNacontractogs)licenupuruatiothe Contractor's ALTER ( )
License law. WATER EA FEE SUMMARY
❑ I um exempt under Sec. B&P C for this reason BACK FLOW PROTEg OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.RD. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
coven� ❑ Ihcrchy xf0rm the lhavevmnilwm of consenno self-insure.oramrtifcamf FIXTURES-PER TR _� RECEIPTp
Wohers'Compenvation lnswance oraceniRW copy themof(Sec.J&00,lab C.)which PARK FEE YN
all employees under this Permit. I RECEIPT k
Poiy# r GAS-HA.SYSTEM-IS
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-
❑ Certified copy is hereby fumisM1W, PIANCHECK FiE❑ Certified copy is filed with the city impmthm division. GREASF/INDUSTRL EPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS'EXEMPTIONEASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need am he cdmplded iffm permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.201
mar.) ENERGY FFEEor l
I certify that in the performanceaf,he work for which this permit is issuW,lshell WATER HEATER WNEN`UrLECIR
not employ any person in any manner w as,m become subject to the WorkersPAID
z Compens:nion Laws of Cuffomia. Data WAT17R SYSTEM/IREATING Dam RtteiptN
Applicant
z 2 NOTICE TO APPLICANIL If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. IOTA
F-' q become subjen melte Worker's Compensmion provisions of the LnMr Code,yromust
a > fonhwitM1 comply with such pmvislnns or'his pami t shall be deemed revoked. BUILDING FEE
6i CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebynffirm'hilt there isonal,metion lending agency for the performance of
U O the work for which this permit is omed(Sec.3097.Ci,C,) ELECTRIC FEE
nder's Name
U LeLendrra Address QTY. MECHANICAL PERMI'i' FEE PLUMBING FEE
I cer'ify that 1 have read this application and sax that the above iofo..6.is
F0. concert. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
(n building consuveuon.and hereby auNorix mpreseoatives.1ma city,.rnfee.,.the
L) slve mentioned property for inspection TION TAX
zoipurposes. ALTER OR ADD TO MECII. CONSTRUC
(We) new to save,indemnity and hoc may ina the City of Cupertino ad City
'iaarom encs,costs and expenses may in any way accmmgainst said City AIR HANDLING UNIT(TO 10,000 CFM)
once ftQ1egranting of tht{y It.
1
t a u o VC� AIR HANDLING UNIT(OVER I O.I100 CFM)
SEgnorm of Applicam/Comrecmr Date EXHAUST HOOD(W/DUCIT
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(*to 100.000 BTU) Date Rttcip,N
Will the applicant or future building medical,smm of handle ha cupi materiel
as defined by the Cupertino Municipal CW,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100 poll BTU)
Colic,Sec'fan 25532oo l
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
Will the applicant or future builiingracupunt uscequipmem ordevices which emit BOILER-COMP QUIP OR 100,00)BTU) ISSUANCE DATE
huallous air contuminana as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU
) 40-410
Diauiar.
❑Yes ❑No NEW RESIDENTIAL MGCII. SQ,ET, A
1 have read the hvadoas materials requiremems under Chapter 6.95 of the ��/)• m J
Califimia Health&Safety Code,Sections 25505,25533 rod 25534.1 understand that !s d
if the building does nav
ot currently heawrion•'but i,is my responsibilitym amify the Cir _
nemPard of the requiremems which must to me,prior to issuance of a Ceniecme of
Occupancy. Ur�ft //V(/
Owner or authnrred agent Ura AL: ISSUED BY
OFFICE